
GonynghtU?.-/^; 



COPYRIGHT DEPOSm 



BOOKS 



GEORGE P. PAUL, M. D, 



Nursing in Acute Infectious Fevers 

i2mo of 275 pages, illustrated. 
Cloth, $1.00 net. Third Edition 



Materia Medica for Nurses 
i2mo of 280 pages. Cloth, 

$1.50 net. Second Edition 



NURSING 

IN THE 

ACUTE INFECTIOUS 
FEVERS 



BY 

GEORGE P. PAUL, M.D. 

TOWN HEALTH OFFICER, ROUND LAKE, NEW YORK J SOMETIME VISITING 
PHYSICIAN TO THE SAMARITAN HOSPITAL AT TROY, NEW YORK 



I llus trat ed 



THIRD EDITION, THOROUGHLY REVISED 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 
1915 






Copyright, 1906, by W. B. Saunders Company. Reprinted August, 1906, and 
November, 1909. Revised, reprinted, and recopyrighted April, 191 1. 
Reprinted February, 1913, and September, 1914. Revised, en- 
tirely reset, reprinted, and recopyrighted October, 1915 



Copyright, 1915, by W. B. Saunders Company 



PRINTED IN AMERICA 



PRESS OF 

W. B. SAUNDERS COMPANY 

PHILADELPHIA 




©CI.A4 10980 



PREFACE TO THE THIRD EDITION 



The reception of the former editions of this work by 
members of the medical and nursing professions has 
been very gratifying to the author. 

This third edition is in enlarged form. Two new 
chapters have been added; several chapters have been 
entirely rewritten and much new material has been 
introduced throughout the whole text. 

It is the author's desire that this present volume will 
serve a greater need than its predecessors. 

G. P. P. 

Round Lake, New York, 
October, 1915. 



PREFACE 



The object of the author in preparing this book is to 
place before the nursing profession a volume which 
will be of practical service. 

The subject-matter is written for the nurse, and not 
the medical graduate or scientific worker, hence all 
extraneous matter and useless discussions are not 
given place. 

The treatment of disease by means of drugs and 
the physical signs are but little discussed, as these are 
of more importance to the medical attendant than to 
the nurse. 

Great pains have been taken in preparing the sec- 
tions on the Care and Management of each disease, 
as this relates directly to the duties of the nurse. 

The book is divided into three parts : The first part 
treats of fever in its general aspects, which is necessary 
as a base to the study of each individual fever ; the 
second part discusses each of the acute infectious 
fevers as to their cause, signs and symptoms, course, 
prognosis, care, and management ; the third part deals 
with practical procedures and information necessary 
in the management of the foregoing diseases or of 
value in understanding the nature and course of such 
diseases. 

ii 



12 PREFACE 

Only illustrations and charts of a specific value are 
included. 

The author wishes to express his thanks to Susan 
D. Munroe, Assistant Superintendent, Samaritan Hos- 
pital, for her kind and candid criticism. 

G. P. P. 



CONTENTS 



PART I— GENERAL CONSIDERATIONS 



CHAPTER I 

Page 

Fever in General 17 

CHAPTER II 
Hygiene of the Sickroom 25 

CHAPTER III 
Diet of the Sick 33 

CHAPTER IV 
Reduction of Fever : 48 

CHAPTER V 
Child Hygiene 56 

CHAPTER VI 
Alleviation of Symptoms 64 

CHAPTER VII 
Detection of Complications 79 



PART II.— SPECIAL DISEASES 



CHAPTER VIII 
Typhoid Fever and Paratyphoid Fever 87 

CHAPTER IX 
Smallpox no 

13 



H CONTENTS 

CHAPTER X 

Page 

Chicken-pox 118 

CHAPTER XI 
Scarlet Fever 120 

CHAPTER XII 
Measles 131 

CHAPTER XIII 
German Measles 137 

CHAPTER XIV 
Mumps 140 

CHAPTER XV 
Whooping-cough 142 

CHAPTER XVI 
Influenza 147 

CHAPTER XVII 
Epidemic Cerebrospinal Meningitis 152 

CHAPTER XVIII 
Acute Epidemic Anterior Poliomyelitis 156 

CHAPTER XIX 
Lobar Pneumonia 166 

CHAPTER XX 
Diphtheria 175 

CHAPTER XXI 
Acute Articular Rheumatism 188 

CHAPTER XXII 
Malarial Fever 193 



CONTENTS 15 

CHAPTER XXIII 

Page 

Erysipelas 201 

CHAPTER XXIV 
Septicemia, Toxemia, and Pyemia 206 

PART III— ADDENDA 
/ 

CHAPTER XXV 
Antitoxins and Bacterial Vaccines 213 

CHAPTER XXVI 
Bacteria 220 

CHAPTER XXVII 
Urine and its Examination 226 

CHAPTER XXVIII 
Signs of the Onset of the Toxic Effects of Drugs . . 234 

CHAPTER XXIX 
Poisons and their Antidotes . . 236 

CHAPTER XXX 
Enemata and Topical Applications 240 

CHAPTER XXXI 
Antiseptics and Disinfection 245 

CHAPTER XXXII 
Abbreviations, Weights and Measures 254 

CHAPTER XXXIII 
Selected Formulas 257 

CHAPTER XXXIV 
Miscellaneous Notes 260 

Index 263 



PART I 
GENERAL CONSIDERATIONS 

CHAPTER I 
FEVER IN GENERAL 

Fever is that condition of the human body in which 
the temperature is raised above the normal. 

The normal human body temperature is 98.6°F., 
but it may vary a little either way, depending upon 
several conditions. 

Physiologically, the temperature of a healthy adult 
is at its lowest between midnight and four o'clock in 
the morning. It is at this time, when the body func- 
tions are at their lowest, that patients ill with grave 
diseases are most likely to pass away. The tempera- 
ture reaches its height between five and eight o'clock 
P. M., and then gradually decreases until early morn- 
ing. In persons who toil at night instead of day this 
ratio may become reversed and the height is reached 
in the morning. 

The normal temperature is lowered in several ways; 
insufficient diet may lower the temperature a fraction 
of a degree. In starvation the temperature may become 
very subnormal. In certain febrile diseases, either be- 
cause insufficient nourishment is provided or because 
the patient swallows but little food, a subnormal tem- 
perature may result, especially in the beginning of 
2 17 



1 8 FEVER NURSING 

convalescence. One of my cases of typhoid fever at 
the beginning of convalescence had attacks in which 
he would enter a state of collapse, the temperature 
would become subnormal, the skin pale and moist, but 
the pulse would remain normal. By careful watching 
we learned that he would hold the milk in his mouth 
until the nurse turned her back or left the room, when 
he would expel it. This he kept up for a week or 
more, probably getting only a fraction of a glassful 
of milk in twenty-four hours. 

Cold drinks lower the temperature temporarily; 
cold baths lower the normal temperature. After tak- 
ing an anaesthetic the temperature is also lower than 
before; and certain drugs, such as morphine, quinine, 
large doses of alcohol, coal-tar preparations, as ace- 
tanilid, antipyrin, phenacetin, etc., will lower the bodily 
heat. During sleep the temperature is lower than in 
the wakeful hours. 

The normal temperature is raised after partaking of 
a liberal diet, or hot drinks; during digestion; by in- 
creased function of the large glands of the body; by 
increased mental activity and muscular exertion. In 
summer the bodily temperature is a little higher than 
in winter. Such drugs as strychnine, atropine and caf- 
feine will raise the temperature. This is a very im- 
portant point, because the continued rise of tempera- 
ture in the convalescence of certain diseases, as typhoid 
fever, may be due to the administration of strychnine. 

Degrees of Temperature. — The normal temperature 
is q8.6°F. or 37°C. The normal temperature of an 
infant is about qq.4°F. and decreasing gradually to the 
normal adult temperature as full growth is obtained. 
After the age of 40 or 50 years the temperature decreases 



FEVER IN GENERAL 1 9 

to about 97.8°F. and in advanced age rises again to 
99.4°F. Thus in both extremes of life the temperature 
is about the same and is above normal. 

95°F. equals Collapse temperature. 

97.5°F. equals Subnormal temperature. 

98.6°F. equals Normal temperature. 

99.5°-ioi.5°F. equals Subfebrile temperature. 

io2°-io3°F. equals Moderately febrile temperature. 

io4°-io5°F. equals Highly febrile temperature. 

Over io6°F. equals Hyperpyretic temperature. 

Detection of Temperature. — This is done by means of 
the clinical thermometer, the bulb of which is placed 
under the tongue and the lips closed, the patient being 
warned not to bite the instrument. The thermometer 
is left in position from one to five minutes, depending 
on the grade and sensitiveness of the instrument. As a 
general rule the temperature is taken by the mouth, but 
at certain times this is either not possible or desirable. 
For example, it is impossible to take the temperature in 
young children by mouth; in adults who are in a comatose 
or semi-comatose condition; and in insane patients. If 
the tongue be dry, the recorded temperature will not be 
accurate, nor if the patient had recently drunk cold or 
hot water. Other situations for taking the temperature 
are in the axilla, in the rectum, in the vagina, and in the 
passing urine. 

Before placing the thermometer in the axilla, the 
armpit should be thoroughly wiped and dried. The 
bulb of the thermometer is then put well into the cen- 
ter of the axilla, and the hand of that side placed on the 
front of the chest so as to completely envelop the bulb 
of the thermometer with the axillary tissues. The 
instrument should be allowed to remain in position 



20 FEVER NURSING 

for five minutes. To the recorded temperature add 
about o.5°F., which will bring it up to the oral 
temperature. 

The instrument may also be placed in the rectum or 
vagina. It is very seldom necessary to use this method 
except in children, or in adults who are unconscious, 
delirious, or insane. If used rectally, the rectum should 
first be emptied of fecal matter, for if the bulb of the 
thermometer be inserted into a mass of feces, an in- 
correct reading is obtained. The rectal temperature, 
when properly taken, is a true index of the degree of 
body heat. 

Another method is by allowing the patient to urinate 
on the bulb of the thermometer. This is an accurate 
method, but applicable to only a few cases. 

In febrile diseases it is best to record the tempera- 
ture every four hours during the acute stage of the 
disease. 

Prognosis. — The prognosis of febrile diseases does 
not entirely depend on the fever, but also on the con- 
comitant symptoms. A fever of io6°F. for a brief 
period is not as grave as one of io5°F. for a more ex- 
tended time. An evening temperature of i04°F. in 
typhoid fever is of more import than fever of io5°F. in 
pneumonia. 

A temperature of io6°F. if continued for several days 
is fatal (Smith). In persons over 50 years of age a 
temperature of io3°F. is serious. 

The relation of the pulse is very important in mak- 
ing a prognosis. If the evening temperature does not 
rise above io4°F. and the pulse is good, the prognosis 
is favorable. In diphtheria a temperature of ioi°F. 
and a pulse of 120 is grave. If the temperature con- 



FEVER IN GENERAL 21 

tinue at io5°F. for four or five hours in a case of typhoid 
fever, the prognosis is grave. 

Children tolerate a higher fever than adults. A 
temperature of io4°F. in a child is of the same import 
as io2°F. in an adult. Disproportion between the 
surface and mouth temperature is serious. 

Sudden and continuous rise of temperature in the 
course of a disease, if all complications can be excluded, is 
usually antemortem. 

Stages of Fever. — Fever may be divided into three 
stages; namely, invasion, fastigium, and decline. 

Invasion extends from the beginning of the febrile 
manifestations until the fever reaches its height. It 
varies in length, degree, and character in various dis- 
eases. In typhoid fever the invasion is of about ten 
days' duration. The fever gradually increases in a 
step-like manner, with diurnal remissions for seven to 
ten days, when it reaches its height. In pneumonia, on 
the other hand, the invasion is very abrupt and of short 
duration. The fever reaches its height, as a rule, in 
twenty-four or forty-eight hours. 

Fastigium is that period when the fever is at its height, 
and extends from the end of the invasion to the beginning 
of decline. In typhoid fever the fastigium is about 
twelve days long. The evening rise reaches about the 
same height every day and the diurnal remission is 
less than the remission during the invasion. In pneu- 
monia the period of the fastigium is shorter than in 
typhoid, lasting as a rule, from four to six days, with 
hardly any remission. 

Decline of fever may take place in one of two ways: 
by lysis, that is, a gradual fall of the fever; or by crisis — 
a sudden fall to normal. The principal diseases in which 



2 2 FEVER NURSING 

the temperature falls by crisis are lobar pneumonia, 
typhus fever, erysipelas, measles, relapsing fever, and 
influenza. In most other diseases the fall is by lysis. 

Types of Fever. — All fevers may be placed under 
three heads: continued, remittent, intermittent. In 
continued fever the temperature remains at a more or 
less constant height, with little or no daily remission. 
Examples of this type are lobar pneumonia and typhoid 
fever. In remittent fever, the diurnal remission is 
marked, but the lowest daily temperature is still above 
the normal, as in malarial remittent fever and in certain 
types of tuberculosis. In intermittent fever the tem- 
perature falls to the normal or subnormal diurnally and 
again rises, as in malarial intermittent fever, relapsing 
fever, and certain forms of tuberculosis. 

Phenomena of Fever. — Rise of temperature may be 
the result or the cause of other concomitant symptoms. 
Among the common accompaniments of fever are head- 
ache, malaise, muscular pains, languor, chilly sensations, 
loss of appetite, coated tongue, tendency to yawn, 
flushed face, glistening eyes, nausea or vomiting, consti- 
pation as a rule, increased rate of pulse and respirations, 
hot and dry skin. The urine is concentrated, small in 
amount, dark in color, of high specific gravity and 
contains albumin. 

Treatment of Fever. — There are eight divisions to the 
proper treatment of fever; namely, neutralize the poison; 
promote elimination; reduce the temperature if high; 
maintain nutrition; stimulate when necessary; relieve 
symptoms; prevent and counteract complications; use 
care in convalescence. 

Neutralize poisons. — 'This is very difficult. In those 
diseases for which we have antitoxins thev should be 



FEVER IN GENERAL 



23 



used early and in sufficient quantity. Hypodermocly- 
sis of normal saline solution is very useful in diluting 
the poisons in the blood and aiding in their elimination. 



OT 










































M 


E 


M 


E 


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10a 

107 

106 

105 
104 
103 
102 
101 
100 
99 
98 
97 




































































108 
107 
106 
105 
104 
103 

m 

101 
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97 

























































































































































































































































Fig. 1. — Temperature chart of a continued fever 



MTt 










































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108 
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Fig. 2. — Temperature chart of a remittent fever. 

In those diseases in which toxins are formed in the 
intestinal tract, certain disinfectants as salol, creosote, 
guaiacol, and thymol are useful. 



24 



FEVER NURSING 



Promote elimination by the bowels with purgatives 
and enemata. By the kidneys in giving plenty of 
water to drink; also rectal infusions and hypoder- 
moclyses of normal saline solution. By the skin with 
hot packs, hot dry air, and hot drinks. 



DM' 
















m 

108 
107 

:-: 


4 8 12 4 8 12 


4 8 12 4 8 12 


4 8 12 4 8 12 


4 8 12 4 8 12 


4 8 12 4 8 12 


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:03 
07 


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103 : j\ 
102 j ' j\ i 
101 1 / | ; 
100 1 / 1 






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Fig. 3. — Temperature chart of an intermittent fc 



Reduce the temperature by hydrotherapeutic meas- 
ures (see subsequent articles) and by means of drugs. 

Maintain nutrition by food of proper quality and in 
proper quantity. 

Stimulation and other headings under general treat- 
ment will be considered in subsequent chapters. 



CHAPTER II 
HYGIENE OF THE SICKROOM 

Ventilation. — -One of the most important consid- 
erations of the sickroom is its ventilation. The refuse 
or altered products of all substances taken into the 
body for its nourishment are eliminated as worthless 
to the human economy and are not to be introduced 
into the system. This is just as true in regard to the 
respiratory system. Air rich in oxygen is inhaled; 
the oxygen is used to maintain the vital processes, 
and a combustion product, known as carbon dioxid, 
and certain organic materials worthless to the human 
being, are exhaled, and are not supposed to return to 
the body. This makes it necessary to provide a free 
exit for these substances from the breathing area of 
the person. 

The oxygen of the inhaled air combines with certain 
elements of the blood and displaces the carbon dioxid 
of the blood. This latter has been carried by the 
circulation from the different parts of the body to the 
lungs, and is eliminated in the expired air, together 
with a small amount of organic material. 

If a person be confined in a closed room, he will in 
a certain time, depending on the size of the room, 
have used all the available oxygen of the air and have 
replaced it with carbon dioxid and organic matter. 
These will begin to act as poisons and destroy the life 

25 



26 FEVER NURSING 

of the person unless he be taken out of the room, or 
fresh air admitted. 

The estimated amount of air space necessary for one 
person is about 2000 cubic feet with a supply of about 
1500 cubic feet per hour. 

Now let us consider the sick person. If a fresh 
supply of air be necessary for an individual who is 
physically strong and in perfect health, how much 
more necessary is fresh air to a person whose body is 
debilitated by illness, whose vital processes are being 
hampered by high fever and toxins? How necessary 
is it to give free exit to the expired air, not only con- 
taining carbon dioxid and organic matter, but also the 
products of bacterial life, and in some instances bacteria 
themselves? 

Ventilation of rooms is brought about in several ways. 
By disproportion between the temperature of the rooms 
and that outside; by the natural diffusion of gases; by 
openings allowing the free entrance and exit of air. 
We will deal only with the last-mentioned means. 

There is a vast difference between draughts and ven- 
tilation. The former are a source of injury but the 
latter is not only not injurious, but very necessary. 
Some people think that in order to ventilate a room it 
is necessary to create a draught. 

There are two useful methods of supplying fresh 
air to the patient. The first is by continuous free 
ventilation; that is, by having a large supply of air 
entering the room constantly. The second method 
consists in having a more limited constant supply, and 
then several times a day, after covering the patient's 
body well and placing a thin cloth over his face, opening 
the windows widelv for a brief time. 



HYGIENE OF THE SICKROOM 



27 



In many modern dwellings the system of ventilation 
is perfect and in these cases manipulating the windows 
is unnecessary, but as a general thing, ventilators in 
houses are such in name only. 




Fig. 4. — Window ventilation. A, A'. Inserted boards. 



A very practical method of arranging the windows 
is as follows: Lower the upper sash from three to six 
inches, raise the lower sash the same distance, and fill 
in the open spaces, above and below, with pieces of 



28 



FEVER NURSING 



board that exactly lit the window frame. At the 
center of the window there is then formed an air space 
between the lower part of the upper pane of glass and 
the upper part of the lower glass, and this space com- 



■~-A 

* f 

•>- » 

a o? 



%. 



^/r 



y i 



"••< <-"; 

..."> 



E' 



■B' 



Fig. 5- — Diagram of window ventilation (side view). A, A', window 
frame; B, B', inserted boards; C, C, window sash; E, E', window glass; 
H, H', currents of air going in and out. 



municates both with the outside air and the inside of 
the room to be ventilated. (See illustrations.) 

All kinds of flames, as in stoves, lamps, and gas jets, 
use up the oxygen of the air. These not only consume 
that which is of vital importance to the patient, but also 
vitiate the air with poisonous and oppressive gases. 



HYGIENE OF THE SICKROOM 20. 

Do not burn more gas or oil in a sickroom than is 
absolutely necessary. It is stated that an ordinary gas 
burner in use consumes more oxygen in one hour than a 
person would use in six hours. 

Dr. Wm. P. Northrup, of New York, has said: "If 
you wish to kill a child who is sick with pneumonia, 
close your windows, start the gas stove, burn a few gas 
jets, have plenty of friends in the room to help use the 
air, and have the temperature of the room above 8o°F." 

We have considered the quantity of air. Of next 
importance is its quality. The air should be of a cer- 
tain temperature. If the person be very feverish, the 
temperature of the room should be between 65°F. and 
68° F., and when the temperature of the patient becomes 
normal or falls below the normal, the temperature of the 
room should approach 7o°F. 

Perfectly dry air is very irritating to the respiratory 
passages, and normally air should be a little moist. In 
houses heated by hot air furnaces it may be necessary to 
dampen the air. This is done by hanging in the room 
towels or cloths dampened with water; or in some cases, 
especially when the patient is ill with a disease of the 
respiratory tract, a steaming apparatus is very useful 
Moisture may also be furnished by simply boiling water 
in the room. 

The Room and Its Furniture.— The room should be 
of fairly good size so as to provide plenty of air space. 
Southern exposure is to be selected if choice be given. 
Plenty of sunshine will not only enliven and brighten the 
patient, but it also acts as a bactericide. The eyes of 
the patient should not face the bright light. Only such 
furniture should remain in the room as is absolutely 
necessary — a bed, one or two small stands, and a couple 



30 FEVER NURSING 

of chairs. In cases of contagious diseases the pictures 
and curtain hangings should be removed. 

Do not allow unused glasses of water to remain in the 
sickroom, and plants and flowers should be excluded. 
A very ill patient will not recognize or appreciate 
flowers, and if he wishes to see them they might be 
placed in an adjoining room within the sight of the 
patient. 

During the insect season the windows and doors of 
the sickroom should be thoroughly screened. Mosqui- 
toes and flies must be kept from the patient's room, be- 
cause of their annoyance to the sick person and their 
likelihood to disseminate disease. 

Preparation of Bed. — -The proper preparation and 
care of the bed is one of the most important duties of 
the nurse. The principal considerations are that the 
bed should be neither hard nor soft; the bedclothing 
should be smooth, and the coverings should be sufficient 
but light. 

Over a good hair mattress are smoothly placed, first, 
a soft blanket, then a cotton sheet. A draw-sheet is 
a very convenient addition. This consists of a sheet so 
folded as to be about three or four feet wide, placed 
crosswise on the undersheet and tucked in under the 
mattress at the sides. It should be placed so the 
buttocks of the patient are midway between the upper 
and lower edges of the draw-sheet. If necessary, a piece 
of rubber sheeting or table oilcloth may be put under the 
draw-sheet to protect the under-bedclothing from 
discharges. Over the patient should be placed a soft 
cotton sheet and a light blanket or quilt. Do not tuck 
these top pieces of bedclothing tautly under the sides 
of the mattress, for it is very annoying for the patient 



HYGIENE OF THE SICKROOM 3 1 

to have the clothing weight down or pull on the toes 
when he is in the supine position. 

The bedclothing of a fever patient should be changed 
without any active movement on the part of the patient. 
By means of a draw-sheet, the patient may be drawn 
from one side to another of the bed, when the soiled 
under-bedclothing may be rolled up as far as the body of 
the patient and the clean clothing be applied over the 
uncovered portion of the bed, with the excess folded and 
placed beside the patient's body; then, by means of a 
draw-sheet, the patient may be lifted over the pile of 
soiled clothing and the folds of new clothing on the 
freshly prepared portion of the bed, when the remainder 
may be adjusted and a new draw-sheet applied. 

Probably the most convenient form of body clothing 
for the patient is a short cotton gown, fastened at the 
back with tapes. 

Quiet. — -Quietness in a sickroom is very essential. 
Only those persons whose services are needful should 
be allowed in the room, and under no circumstances 
should any person outside of the immediate family 
and spiritual advisor be permitted to enter the room 
during the acute course of the disease. 

Loud talking and noises of all kinds should be pro- 
hibited both inside and outside of the room. All con- 
versation in the sickroom should be carried on in a low, 
soft voice, but not in a whisper. It is very unwise to 
converse in the sickroom in such a manner that the 
patient can not hear it, for it at once arouses his curiosity 
and may excite him. If you have anything to say to the 
physician or attendants which the patient should not 
hear, postpone saying it until you leave the room. 

In the acute fevers of children probably quiet is even 



32 FEVER NURSING 

more necessary than for adults. The child should rest 
quietly in bed and not held in the laps of elders and 
passed on from one to another, as this is very enervating 
and exhausts the little patient, and may bring about a 
fatal issue which otherwise could be averted. Attempts 
should not be made to entertain small children ill with 
one of the fevers, neither should they be urged to look 
at pictures or read to. Every chance should be given the 
recuperative powers to bring the little patient again to 
the state of health. 

The clothing of the child should be light, and swad- 
dling be relegated to the domain of ancient customs. 
The feet of all ill children should be kept warm by means 
of the hot-water bags, hot foot-blankets or heated irons 
or cloths. The room should be well ventilated and the 
access of fresh air made free. 

The child should be urged to drink sufficient water. 
A daily morning cleansing bath of warm water is re- 
quired and a nightly warm bath is conducive of rest- 
fulness. A daily bowel movement is very important. 

The febrile disturbance in children is best met by 
means of a cool or tepid-water sponge followed by an 
alcohol rub, and by the employment of cold chest and 
abdomen packs. 

The diet, as in adults, should be reduced. 



/ 



CHAPTER III 
DIET OF THE SICK 

A foodstuff is that substance which, when introduced 
into the human body, is digested and assimilated, aids 
in the formation of new tissues, prevents the waste of 
tissue, or helps in the production of heat and 
energy. 

Food is a collection of foodstuffs to supply those 
elements necessary to maintain life. The five funda- 
mental foodstuffs are nitrogenous bodies, as proteids, 
carbohydrates, fats, inorganic salts, and water. The 
principal elements found in foodstuffs are nitrogen, 
hydrogen, oxygen, carbon, phosphorus, and sulphur. 

The proteids contain all the mentioned elements, and 
serve to form new tissues, supply nervous energy, and 
create heat. 

The carbohydrates contain hydrogen, oxygen, and 
carbon, provide heat or at times form fat, but cannot 
form other tissues. 

The fats contain the same elements as the carbohy- 
drates, and perform the same functions. 

The water and salts supply and keep up the normal 
percentages of these substances in the body. 

From what has been said above it will be easily under- 
stood that an absolute diet of fats and carbohydrates 
will not suffice, as these bodies do not supply nitrogen 
3 33 



34 FEVER NURSING 

which is necessary for building new tissues. On the 
other hand, life may be sustained on a diet with these 
two foodstuffs omitted. 

The chief requisites of food are that it be well cooked; 
that it be in good form; be pleasing to the eye; taste 
well, and contain in good proportion all those elements 
necessary to maintain life. 

Frequency of Feeding. — In acute infectious fevers 
food plays as important a part as medicines. It is in 
these cases that "support" of the patient depends on 
the food. 

During the course of the disease food must be given 
just as regularly as medicine, every two or three hours 
being usually frequent enough. About night feeding 
there is much debate, some authorities not wishing 
their patients awakened for food. It is an established 
fact that the vital functions are at their lowest in the 
early morning hours, and often a glass of milk or other 
nourishment has turned the tide for the better in ady- 
namic conditions at this time. It is better to give the 
medicine and nourishment at the same time during 
the night, so as to avoid frequent awaking of the 
patient. 

Milk. — No one substance forms an ideal food, but 
of all substances milk comes nearest to being perfect. 
In milk all the elementary foodstuffs will be found. 
Proteid in the casein; carbohydrates as milk sugar; 
fats in the cream; inorganic salts as calcium phosphate, 
potassium chlorid, etc.; and water represented by the 
fluid portion. 

In fevers milk forms the sole diet. This subject has 
been the cause of much debate and good points have 
been brought up on both sides. Those in favor of a 



DIET OF THE SICK 35 

milk diet say that life can be supported indefinitely on 
milk, that it is not irritating to the intestinal tract, that 
it leaves very little residue, that it is easily obtained and 
is cheap, that it is readily digested by most persons and 
if not, it may be artificially digested. Other authorities 
say that to many individuals milk is distasteful, it 
causes the formation of gas and tympanites, that it does 
not contain in proper proportion the elements necessary 
to the sustenance of animal life, that the excess of lime 
salts predispose to thrombi formation, that in order to 
get sufficient nourishment enormous amounts must be 
given, which will overburden the digestive apparatus. 

The daily amount of milk necessary is between three 
pints and two quarts. If five ounces of milk be given 
every two hours, it will, as a rule, be sufficient. Many 
persons cannot take undiluted milk. In these cases 
the milk may be diluted with lime water, barley water, 
oatmeal water, or vichy. 

In profound conditions the process of digestion 
must be aided. This may be done by giving pepsin 
and dilute hydrochloric acid after the administration 
of the milk, or by digesting the milk wholly or in part 
(see peptonized milk below). 

It is often necessary when nursing children are taken 
ill with a contagious disease, to cease feeding them 
with the milk from the mother's breasts, and to modify 
cow's milk so that it will approach the composition of 
the mother's milk. Following will be found a convenient 
scheme for modifying cow's milk. 



2,6 FEVER NURSING 

MODIFICATION OF COW'S MILK FOR INFANT FEEDING 

I. Compositions of the Various Milks. 

Percentage of 
Fat. Sugar. Proteid. 

(a) Cow's Milk, 44 4 

(b) Gravity Cream, 16 4 4 

(c) Human Milk (high), 47 2 

(d) Human Milk (low), 36 1 

II. Feeding at Various Ages. 

(a) Birth to 1st Month, 1 6 1 

(b) Birth to 1st Month, 2 6 1 

(c) Birth to 1 st Month, 2 6 0.66 

(d) 2nd to 4th Month, 36 1 

(e) 4th to 1 2 th Month, 47 2 

(f) After 1 2th Month, 44 4 

III. Daily Feedings and Amount of Milk. 

(a) 1st Month, 8 Day and 2 Night Feedings, each 

2 Ounces. 

(b) 2nd Month, 8 Day and 1 Night Feeding, each 

3 Ounces. 

(c) 3rd Month, 8 Day and o Night Feedings, each 

4 Ounces. 

(d) 4th Month, 7 Day and o Night Feedings, each 

5 Ounces. 

(e) 6th Month, 6 Day and o Night Feedings, each 

7 Ounces. 

(f) 10th Month, 5 Day and o Night Feedings, each 

8 Ounces. 

IV. Total Daily Amount of Milk. 

(a) 1 st Month, 20 Ounces. 

(b) 2nd Month, 27 Ounces. 

(c) 3rd Month, 32 Ounces. 



DIET OF THE SICK 37 

(d) 4th Month, 35 Ounces. 

(e) 6th Month, 42 Ounces. 

(f) 10th Month, 40 Ounces. 

V. Methods of Obtaining the Various Compositions. 

(a) Formula 1-6-1. 

Parts. Fat. Sugar. Proteid. 

Milk, (2) 8 8 8 

Boiled Water, (6) o o o 



(8) 



Sugar of Milk 5%, 





1 


6 


1 


(b) Formula 2-6-1. 








Milk, (2) 


8 


8 


8 


Gravity Cream, (1) 


16 


4 


4 


Boiled Water, (9) 











(12) 


24 


12 


12 



Sugar of Milk 5%, 



(c) Formula 2-6-0.66. 

Gravity Cream, (2) 32 



3» 



I FEVER 

Milk, (i) 
Boiled Water, (15) 


NURSING 

4 




4 



4 




(18) 


36 


12 


12 


Sugar of Milk 5%, 


2 
5 


0.66 


0.66 


(d) Formula 4-7-2. 
Gravity Cream, (1) 
Milk, (2) 
Boiled Water, (3) 


2 

16 

8 



6(-) 

4 
8 



0.66 

4 
8 



(6) 


(24) 


12 


12 


Sugar of Milk 5%, 


4 


2 
5 


2 


(e) Formula 3-6-1. 
Gravity Cream, (2) 
Milk, (1) 
Boiled Water, (9) 


4 

4 



7 

8 

4 



2 

8 

4 




(l2) 36 12 12 



3 1 1 

Sugar of Milk 5%, 5 

VI. An example: The child is four months old and 
must be fed artificially. How will the nurse prepare 



DIET OF THE SICK 39 

the milk? Tables II and III tell me that a child of four 
months will require seven day feedings, each of five 
ounces of a milk whose composition is 4-7-2. Table 
V (d) says this formula is made by taking 1 part of 
gravity cream, 2 parts of cow's milk, 3 parts of boiled 
water and five per cent, of milk sugar. 

Table IV shows that the amount to prepare for one 
days is thirty-five ounces. Therefore, take of gravity 
cream, 1 part or five and five-sixths ounces; of cow's 
milk, 2 parts or eleven and two- thirds ounces; of boiled 
water, 3 parts or seventeen and one-half ounces; of 
milk sugar, five per cent, or one and three-fourth ounces. 
It is best to replace part of the water with lime water 
(two or three ounces). 

Gravity cream is obtained by removing the cream 
from a vessel of milk which has been allowed to stand 
in a cool place, preferably on ice, for four or five hours. 

The question of diet for sick children seems to be a 
difficult one for most mothers. The food is usually 
given according to the child's whims and caprices 
rather than for its welfare. Diet should be strictly 
regulated as to form, quantity and frequency. I have 
seen but few ill children but what will soon take the food 
prescribed, regardless of their former habits, if handled 
rightly. A sick child is not the proper person to consult 
regarding its diet. For all children, except in very ex- 
ceptional cases, milk will form the basis of diet. To 
those under twelve months it will be the absolute diet, 
whereas those older may have other articles added. 

Children under twelve months if on the bottle may 
continue on the same mixture but made one-third to one- 
half weaker by the addition of plain boiled water. 
For breast-fed infants the reduction may be accom- 



40 



FEVER NURSING 



plished by giving the child water or barley water before 
each nursing. If it is necessary to put a breast-fed child 
on a bottle the following formulas may help. 

One to three months : 

Gravity Cream, 2 ounces 

Milk, 6 ounces 

Sugar of Milk, 1 ounce 

Lime or Barley Water, 2 ounces 

Boiled Water to make 32 ounces 

Give two to four ounces every two hours during day 
and four hours at night. 

Three to six months : 

Gravity Cream, 3 ounces 

Milk 10 ounces 

Sugar of Milk, 1 ounce 

Lime or Barley Water, 4 ounces 

Boiled Water to make, 40 ounces 

Give four ounces every two hours during day and four 
hours at night. 



Six to nine months : 

Gravity Cream, 

Milk, 

Sugar of Milk, 

Lime or Barley Water, 

Boiled Water to make, 



4 ounces 

15 ounces 

1 ounce 

6 ounces 

42 ounces 



Give four to six ounces every two hours during day and 
four hours at night. 



DIET OF THE SICK 4 1 



Nine to twelve months : 




Gravity Cream, 


6 ounces 


Milk, 


20 ounces 


Sugar of Milk, 


1 ounce 


Lime or Barley Water, 


6 ounces 



Boiled Water to make, 48 ounces 

Give four to six ounces every two hours during day and 
four hours at night. 

Eggs contain all elements, but the amount of car- 
bohydrates is very small. Eggs in the form of egg 
water or albumen water (see below) are very useful 
in fevers; also as egg nogs, punches, and prepared in 
various ways. 

Meats are rich in nitrogenous material, and are 
useful chiefly in the forms of broths, consomme, etc. 

Meat broths have a tendency to cause diarrhea when 
given in fevers. For various meat recipes see below. 

Fever Diet. — -The dietary of a person ill with any of 
the infectious fevers is a question of vital importance. 
The author, after much study, now follows more or less 
closely the following scheme. 

From six or eight o'clock in the morning until eight or 
ten o'clock at night, the patient is placed on two-hour 
feedings, but during the night the interval between 
feedings is extended to four hours. 

Alternate feedings must consist of a glass of milk to 
which has been added the beaten white of one egg and 
two teaspoonfuls of milk sugar. If raw milk can not 
be taken then it may be peptonized before the egg white 
and milk sugar are added. The odd feedings may vary, 
consisting of any of the following articles: junket, gela- 
tine, albumen orangeade, cream of wheat gruel, cocoa, 



42 FEVER NURSING 

farina gruel, boiled rice, custard, tapioca cream, oyster 
milk, clam milk, luap and koumiss. 

Meat broths or any meat derivative are omitted from, 
fever dietary by the author because of their liability to 
irritate the kidneys. These organs usually feel the 
brunt of the toxemia of the febrile diseases and should 
not be further taxed by the diet. 

Below is appended the recipes for preparing foods 
useful in the course or convalescence of fevers. 

RECIPES FOR SICK DIETARY 

Barley Water. — -(I) Mix one tablespoonful of barley 
flour with four tablespoonfuls of cold water, make 
a smooth paste free from lumps. Pour this into a pan 
containing one pint of boiling water and stir while 
boiling for five minutes. 

(II) Place one tablespoonful of pearl barley in a 
pan and add one pint of cold water and boil for a few 
minutes, then pour off the water and replace with one 
and one-half pints of clean water and allow it to simmer 
gently for one hour. Strain. 

Oatmeal Water.— To one pint of cold water add 
one tablespoonful of oatmeal and boil for three hours. 
Replace water as it boils away, and then strain. 

Arrowroot Water. — Make a paste of two table- 
spoonfuls of arrowroot powder with a small amount 
of cold water; then add gradually, stirring constantly, 
one pint of cold water. Let it simmer for five or ten 
minutes. 

Albumen Water. — -S train the whites of several eggs 
through a cloth, add an equal amount of cold water, 
and stir well. A little lemon juice and salt may be 
added to taste. 



DIET OF THE SICK 43 

Toast Water. — Toast to dark brown, but do not 
burn, three slices of dry bread. Place in a dish and 
pour over them two pints of boiling water. Cover 
well and let stand on ice until cold; then strain and 
add sugar and flavoring agents. 

Rice Water. — 'Place two tablespoonfuls of cleaned 
rice in one quart of boiling water, and let simmer for 
two hours. Strain and add salt. 

Lime Water. — -Place a piece of lime the size of a small 
egg in a quart, tight-stoppered bottle, and add a half- 
cupful of cool water; allow to stand over night and 
strain. To this washed lime add one quart of fresh 
cool water, shake occasionally and allow to stand 
for twenty-four hours. The clear supernatant liquid is 
then ready for use. 

Flaxseed Tea. — -Take of whole flaxseed one ounce, 
sugar one ounce, licorice root one-half ounce, and 
lemon juice one ounce. To these add one quart of 
boiling water and allow the whole to stand in a hot 
place for four hours. Strain and use. 

Imperial Drink. — -To a quart of boiling water add 
two level teaspoonfuls of cream of tartar, the juice 
of one lemon, sugar to taste, and serve cold. 

Beef Tea. — -Grind or cut fine one pound of lean beef 
and with a pint of cold water place in a saucepan and 
let it stand for one hour, then place on stove and allow 
it to simmer for thirty minutes, strain and season with 
salt. 

Meat Jelly. — Boil slowly in as little water as possible 
a four-pound chicken until tender, then remove the meat 
and let the liquor simmer until quite concentrated. Add 
salt to taste and pour into a mold or bowl and allow to 
thicken. 



44 FEVER NURSING 

Raw Meat Juice. — -Mince finely one pound of lean 
beef and place in a vessel with sufficient cold water to 
cover it. Let stand for four hours and strain through 
cloth. 

Whey. — 'Powder a rennet or junket tablet and mix 
with two tablespoonfuls of water. Heat one quart 
of milk until luke warm, add the rennet solution and stir 
until mixed. When the mass is coagulated cut up with 
a silver knife and strain off the whey. Sweeten to taste. 

Wine Whey. — Bring one pint of milk to the boil- 
ing point and add one gill of sherry wine. Allow to 
stand in a warm place for ten minutes and strain. 
Lemon juice may be used instead of wine. 

Milk Punch. — -To a glass of milk add two teaspoonfuls 
of brandy or whiskey, and sweeten to taste. 

Junket. — To one pint of sweet milk add a pinch of 
sugar and two teaspoonfuls of liquid rennet, or a half- 
grain tablet of rennin, in a tablespoonful of water, 
then pour into a proper receptacle and place near stove 
until coagulation begins, when it is cooled. 

Cocoa Junket. — Rub into a smooth paste a heaping 
tablespoonful of cocoa powder, a tablespoonful of sugar 
and sufficient hot (boiling) water. Thin with three cup- 
fuls of milk and add the rennet mixture as directed above. 

Albumen Milk. — -Mix equal parts of milk and albu- 
men water (see above), shake very thoroughly and 
serve at once. 

Oyster Milk. — Cook a quarter pint of oysters in a 
very small quantity of water for ten minutes, strain, 
and to the liquid add sufficient hot milk to make a 
pint. Salt to taste but add no pepper or butter. 

Clam Milk. — -Prepare same as oyster milk, using six 
clams to the pint. 



DIET OF THE SICK 45 

Luap. — Break one or two small soda crackers in small 
pieces and add to them enough hot water to thoroughly 
soften but not drain. Place a cupful of milk on stove 
and heat well but don't boil. Beat a whole egg thor- 
oughly in a small bowl and add the cracker mass to 
the egg and then while stirring add the warm milk. 
Salt, sugar and nutmeg to taste. 

Boiled Custard.— Beat the yolks of two eggs with a 
tablespoonful or more of sugar and a pinch of salt, 
and gradually add, with constant stirring, a pint of 
boiling milk, then cook until it thickens, probably four 
minutes. 

Egg Nog. — -An egg is beaten well with a glassful 
of milk, and while stirring add a half -ounce of brandy 
or whiskey. 

Kumiss. — (I) Dissolve a half ounce of sugar in three 
ounces of water and twenty grains of yeast in three 
ounces of milk. Pour both into a bottle and add milk 
to make one quart. Cork and wire the bottle tightly, 
shaking at intervals daily for four days. 

(II) One quart of fresh milk, one-third of a cake 
of compressed yeast, one tablespoonful of sugar. Mix 
the yeast with a little warm water, add the sugar to 
the milk, which should be lukewarm, then add the 
yeast and stir well. Bottle as above and set in a warm 
place for twelve hours; then, after placing inverted on 
the ice for twelve hours, it is ready for use. 

Peptonized Milk. — To a pint of milk add five grains 
of pancreatin and twenty grains of sodium bicarbonate 
which have been dissolved in one ounce of water. Keep 
at a temperature of no° F. for one hour, then raise to 
the boiling point for a moment, and place on ice. 

Peptonized Beef Tea. — To one pint of beef tea add 



46 FEVER NURSING 

pancreatin and sodium bicarbonate as in peptonized 
milk, and keep at ioo°F. for three hours; then strain 
and boil for one minute. 

Peptonized Oysters. — To one-half pint of oysters 
which have been finely minced, add pancreatin and 
sodium bicarbonate as in peptonized milk, keep at a 
temperature of ioo°F. for one hour, then add one pint 
of milk and keep at the same heat for another hour. 
Boil for one minute, strain, and salt to taste. 

Peptonized Toast. — To one piece of toast, cut in 
small pieces, add one pint of milk and mince thoroughly; 
then add pancreatin and sodium bicarbonate as in 
peptonized milk. Raise to ioo°F. for two hours, then 
boil for a moment, and strain or not according to the 
condition. 

Farina Gruel. — -Sprinkle slowly into a half-pint of 
boiling salted water two tablespoonfuls of farina and 
continue to boil for twenty minutes, using care that it 
does not burn or adhere to the pan; then gradually 
stir in sufficient hot milk to make a pint, and sweeten 
to taste. 

Cream of Wheat Gruel. — Into a quart of boiling water, 
to which has been added a half teaspoonful of salt, 
slowly stir three tablespoonfuls of cream of wheat, 
or other like cereal. Allow to boil well for twenty 
minutes and add a little butter and sufficient hot milk 
to make a thin gruel. Sugar may be added. 

Oatmeal Gruel. — 'Place in a porcelain pan two cupfuls 
of cold water and a half cup of rolled oats, allow it to 
boil 30 minutes and then strain through a sieve. Add 
sufficient hot milk to make a thin gruel. Salt and sugar 
to taste. 

Corn Meal Gruel. — -To one pint of boiling water slowly 



DIET OF THE SICK 47 

add a tablespoonful of yellow corn meal. Allow to 
boil thirty minutes and thin with hot milk. Add salt 
and sugar to taste. 

Tapioca Gruel. — Soak i tablespoonful of pearl tapioca 
in cold water over night, then strain and add the tapioca 
to two cupfuls of milk and boil for thirty minutes. 
This may or may not be strained. Add salt and sugar 
to taste. 

Gelatine. — -Soak three level teaspoonfuls of granular 
gelatine in a half-cup of cold water for fifteen minutes, 
then to it add sufficient boiling water to make a pint. 
Sweeten, flavor with lemon, strain, and set aside to 
cool. 



CHAPTER IV 
REDUCTION OF FEVER 

Fever is reduced by two methods, the use of drugs 
and by hydrotherapy. The first method we will not 
consider. 

Hydrotherapy is the use of water in the treatment 
of disease. Water is applied to the body in two ways, 
the mediate and the immediate. By the first method 
the water does not come in contact with the body as 
it is applied in receptacles made of rubber or water- 
tight tissues. By the immediate method the water is 
brought in direct contact with the skin. 

Mediate Method. — The ice-bag is probably the 
most common form of mediate application. These bags 




Fig. 6. — Ice-bag (Ashton). 

are made of thin rubber, or may be improvised at 
home by using the dried bladder of a pig or sheep. 
This makes a very good substitute for the rubber bag. 
Into the receptacle place a quantity of ice which has 
been cracked finely. Do not place too much ice in the 

48 



REDUCTION OF FEVER 49 

bag, as it makes it very bulky and heavy, and it be- 
comes a burden to the patient. It is very difficult to get 
a good ice bag, as most of them will soon leak at their 
necks. Between the skin and the ice bag a soft, thin 
woolen cloth should be inserted, to prevent pain and 
necrosis of tissue — -which have followed the neglect of 
this precaution. 

Instead of using ice, ice water may be used, but this 
method requires frequent changing as the water quickly 
becomes warm. 

Another similar method is that known as the ice 
poultice. Powdered ice is mixed with sufficient saw- 
dust to prevent dripping of water and the mixture is 
placed in a flannel bag and covered with oiled silk or 
oiled muslin. 

The cold water coil is a very good form for applying 
cold by the mediate process. This consists of a great 
length of small-caliber rubber tubing coiled in various 
shapes, depending on the part of the body for which 
it is to be used. A certain length at either end of the 
tube is not coiled, one end being used as an entrance 
for the water and the other as an outflow. The coil 
is applied to the body, particularly the abdomen, chest, 
and head, and the inflow end of the tube is placed in a 
pail of ice water elevated above the level of the body of 
the patient. The ouflow end is placed in an empty pail 
on the floor. The water is started flowing by suction on 
the outflow end. When the upper pail has been relieved 
of its water it is refilled from the lower pail. (See Fig. 7.) 
The water bed consists of a large rubber mattress in 
which cold water is placed and the patient allowed to 
lie on it. This method is not frequently used. 
Immediate Methods.— The use of baths in the treat- 
4 



50 FEVER NURSING 

ment of diseased conditions has long been in vogue, and, 
unlike other forms of ancient therapeutic measures, has 
not fallen into disuse, but, on the other hand, is being 
employed more and more as time moves onward. 

The therapeutic indications for the use of baths are 
many. There is a false belief among many that the 
only value derived from the use of cold baths is the 
reduction of fever. This is entirely erroneous, for, 
although the lowering of high temperatures by means of 
cold baths is of great importance, however, it is not para- 
mount. Cold baths are employed for the purpose of 
reducing fever, quieting delirium, calming restlessness, 
overcoming insomnia, toning the nervous system and 
stimulating the vasomotor and circulatory functions. 
Most authorities do not employ hydrotherapeutic 
measures for antipyretic purposes until the temperature 
becomes 103 °F. or more. To meet the other indications, 
cold is employed whenever these conditions are present, 
regardless of the temperature, unless it be subnormal. 

The forms of baths are many. Among the most em- 
ployed forms are the tub bath, bed bath, sponge bath, 
sheet bath, foot bath, and sitz bath. 

Tub Bath. — As the name would indicate, this type 
of bath requires the use of a tub. In hospital practice 
the portable bathtub, which may be brought to the 
bedside, is very handy and makes this form of bath 
less burdensome. In private practice the portable bath- 
tub is in most instances out of the question, and the 
patient must be made portable, which may prove seri- 
ous. The first consideration is the transporting of the 
patient to the tub. With the aid of one assistant this 
may be easily accomplished with a not too ponderous 
patient. It must be firmly impressed upon the patient 



REDUCTION OF FEVER 5 1 

that he is to exert himself in no way, and is to remain 
entirely passive. Another method is by placing the 
patient on a light stretcher while in bed, and carry 
him to the tub. Some of the portable bathtubs are 
provided with a stretcher and a frame by which the 
patient may be easily lowered into and raised from 
the water by means of a crank. The next point of 
importance is the temperature of the water. Shall the 
patient be placed in cold water at once or not? This 
is a much debated question. The shock due to sudden 
immersion into cold water is advocated by some physi- 
cians as being very beneficial, whereas, others say this 
shock is detrimental and should be avoided by placing 
the patient first in warm water and then gradually 
lowering the temperature of the water. It may be 
accepted as a safe rule, that patients that are robust 
and not overwhelmed by the disease from which they 
are suffering may be placed at once in the cool water. 
Before bathing debilitated or weak patients it is wise 
to administer a transient stimulant, as spirit of ether 
or aromatic spirit of ammonia. The temperature of the 
water should be 7o°F. and should be kept at this point 
by adding cold water from time to time, or by means 
of ice in a cloth bag placed in the water. The tem- 
perature of the water is raised by the abstraction of 
heat from the body. It is very important that the 
surface of the patient's body be constantly rubbed, so as 
to maintain the peripheral circulation. 

Friction of the surface is absolutely necessary, as it 
prevents chilling and internal congestions, and also aids 
in more rapid elimination of heat. An ice cap placed 
on the head will obviate troublesome cerebral congestion. 

The patient should remain in the water fifteen or 



52 EEVER NURSING 

twenty minutes or until the temperature is reduced to 
ioo.5°F. After the patient is removed from the cold 
bath the temperature may continue to fall, and if 
lowered below ioo.5°F. by the bath, he may later enter 
collapse. 

When the bath is completed the patient should be 
gently dried, placed in bed and covered only with a 
sheet. If chilliness continues for any length of time, a 
few hot water bottles may be placed around the lower 
extremities of the patient. 

In conclusion let me repeat two maxims: Constant 
friction or rubbing of the surface is important. Do 
not reduce the temperature below ioo.5°F. 

Bed Bath. — This is really a tub bath applied to a 
patient in bed. It is useful, in that the patient is not 
removed from his bed, and the results are about as good 
as those derived from a tub bath. 

The bed bath is easily arranged. A rubber sheet of 
large size is first placed under the patient, then a large 
blanket is rolled lengthwise, so as to form a large bolster, 
which is then placed under the side of the rubber sheet 
and running parallel with the patient's body; a second 
blanket is arranged as the first but placed under the rub- 
ber sheet on the opposite side of the patient; this forms 
a trough in which the patient lies, the ends of the tub 
are formed by placing one or two pillows under the ends 
of the rubber sheet. The pillows at the head of the 
tub will also act as a support to the patient's head. The 
tub being complete, water may now be poured into 
the improvised rubber bathtub. (See Fig. 8.) 

It is well to have a cotton sheet under the patient, to 
prevent the body from coming in contact with the harsh 
rubber sheet. 







r° O 

•a S 
i> o 

= J3 









o«.£ 



5«ft 



^ 5 >> 

q~ 



1 O 1) 

J2 P. 

"0 o 






REDUCTION OF FEVER 53 

The bath is given in the same way and with the same 
precautions as a tub bath. 

When the bath has been completed the water is re- 
moved by taking away a part of the foot pillow and 
lower end of the side bolster, and thus form a sluice for 
the escape of water into a pail held under the gate. The 
rubber sheet is then removed, the patient gently dried 
and covered with a light sheet. 

I consider this form of bath a most excellent one for 
many obvious reasons. The patient is not disturbed, 
and the tub may be easily and quickly improvised in any 
house. If a rubber sheet is not handy, a large piece of 
table oilcloth will serve the same purpose. 

Sponge Bath. — This is one of the most used and 
beneficial forms of hydrotherapeutic measures. Many 
practitioners prefer the sponge bath to all other baths 
and have it used exclusively in the treatment of their 
fever patients. 

A rubber sheet is first placed under the patient, then 
with a moist sponge the surface of the body is covered 
with a thin film of cold water. If the water is applied 
in this manner, evaporation, hence heat elimination, 
results more rapidly than were the patient deluged with 
water. It is necessary to constantly apply friction to 
the body surface to maintain the peripheral circulation 
and to aid evaporation. 

In weak and timid patients it may be wise to sponge 
only part of the body at a time. 

It is necessary to sponge and rub the back, for it is 
here that passive congestions occur, and much heat is 
stored in the thick tissues of these parts. 

Sheet Bath or Packs. — With this form of bath I have 



54 FEVER NURSING 

obtained more beneficial results than with the tub or 
sponge baths in selected cases. 

An arrangement similar to the bed bath, but more 
shallow, may be made, or simply place a rubber sheet 
or piece of table oilcloth under the patient. The patient 
is then wrapped in an ordinary sheet from "chin to 
toes," and sprinkled with cold water until the sheet is 
thoroughly wet, then rub ~ the patient's body actively. 
This is important. As the sheet becomes warm, pour 
on more cold water. 

In ten or fifteen minutes the wet sheet and rubber 
cloth are removed and the patient covered with a light 
cotton sheet. 

Foot Baths. — The uses of this form of bath differ 
from those discussed above. The foot bath or pedi- 
luvium is used principally to influence the circulation 
of the body in insomnia, headaches and beginning acute 
diseases, and also as a means of relieving local pains. 

The feet, and legs nearly to the knees, are placed in a 
deep tub of hot water, and more hot water is added 
as the parts become accustomed to the heat. This 
soaking is continued for ten or fifteen minutes. 

Mustard if added to the water will enhance the action. 
Use one ounce of mustard-flour to a gallon of warm 
water. 

Sitz Bath. — -This form of bath is taken in the sitting 
(sitz) posture and is used to influence the pelvic circula- 
tion. It is employed in suppression of menstruation, 
dysmenorrhea, chordee, etc. 

The buttocks are immersed in hot water. A blanket 
is wrapped about the upper part of the body and draped 
over the tub, to prevent the loss of heat. The patient 
remains in this position about fifteen minutes. 



REDUCTION OF FEVER 55 

Temperature of Baths. — 

Hot, no°F. to ioo°F. 

Warm, o8°F. to 88°F. 

Cool, 88°F. to 7o°F. 

Cold, 7o°F. to 5o°F. 

Notes on Bathing. — It is not wise to continue a bath 
more than from twenty minutes to a half-hour. Do 
not reduce the temperature of a patient below 100.5 
F. as collapse may result. Do not wait for the time 
or temperature limit if the patient become depressed 
or enters collapse, but remove the patient at once and 
apply stimulants. 



CHAPTER V 
CHILD HYGIENE 

The basis of good health of the family, of the com- 
munity, or of the nation depends not upon the cure of 
disease but on the prevention of disease. 

The prevention of disease must be considered in a 
twofold manner: First, to hinder ourselves when well 
from contracting disease from others or outside sources; 
and secondly, to prevent ourselves when sick from 
giving disease to others. 

The primal instinct of man is self-preservation from 
injury, infringement and disease; but comparatively 
few give little thought to guarding their neighbors from 
disease. For an individual to withstand the incurring 
of sickness, two fundamental principles are possible: the 
preparation and development of our bodies and systems 
so that they may overcome and conquer disease elements, 
and also by keeping away from or rendering non- 
dangerous the sources of infection. 

The well-developed and rugged child is not so apt to 
contract illness as the puny child, and if ill has greater 
chances for recovery. Nearly all children in early age 
have about the same opportunity for becoming healthy 
individuals, but many lose this because of environment 
or lack of care and instruction on the part of the parents. 

Nourishment— The development of the child depends 
upon the food of which it partakes. Unless absolutely 
impossible, the food for the first twelve months of the 

«;6 



CHILD HYGIENE 57 

child's life should be the mother's milk. The natural 
breast milk should not be withheld from the child on the 
least provocation but only when it becomes positively 
imperative. The breast-fed child develops more per- 
fectly, is less liable by a great margin to contract con- 
tagious or infectious fevers and has far greater re- 
cuperative powers. The digestive system of the breast- 
fed child, upon which we have to depend so much in 
sickness, is more likely to be in a healthy and stronger 
condition. 

After the age of twelve months, breast milk should be 
discontinued; in other words, the child should be weaned. 
Milk will form the base of diet for some time after the 
first year, but the introduction of other articles of food 
is necessary and important. Cereal foods are one of the 
first innovations in diet. These should be thoroughly 
cooked, not for ten or fifteen minutes, but for two or 
three hours. Oatmeal, cream of wheat, farina and 
hominy in the form of gruels, jellies and later porridge 
with milk, butter and sugar are very good. Bread a day 
or two old or, better, zwieback may be given. Soft- 
boiled egg is an extremely good food, but should be mixed 
with some other article of diet as zwieback crumbs. 
Meat juice occasionally is useful. The juice of an 
orange should be given daily and tends to do much good. 
The meals should be given regularly and under no 
conditions should eating between meals be allowed, 
neither should a child be encouraged in the habit of 
craving one article of food as crackers, fancy cakes or 
bread alone. As already mentioned, the meals should 
be regular, say, for a child under eighteen months of age, 
five or six daily. As time goes on other articles of diet 
may be allowed, as meat broths, potato, vegetables, 



58 FEVER NURSING 

chicken, puddings, and fruits. Do not feed a child 
confectionery, cake or pastries. These are not neces- 
sary to the child's growth and development and may 
even be the means of transforming a healthy child into a 
chronic invalid. 

Sleep is essential to the perfect development of the 
child. During the early days of life, the infant sleeps 
about seven-eighths of the time, and as time goes on it 
sleeps less until the end of the first year fifteen hours is 
sufficient, that is, a twelve-hour night rest and three 
hours in day naps. Every child up to the age of six 
years should have day naps. 

Air. — Outdoor air and abundant fresh air indoors is 
absolutely necessary to the well-being of the child. It 
seems to be the general opinion that a baby or child 
does not need fresh air. As much time as is feasible 
should be passed out of doors. A child under one year 
of age should not go out during cold weather, that is, 
when the temperature is below i8°F. A child under 
four years of age should not go out during windy, damp 
or inclement weather. A child when out of doors should 
not be allowed to stand in drafty places or sit upon cold 
stones. When it is impracticable to take children out of 
doors they should be given the opportunity of indoor 
airing. This may be done by clothing them as you would 
for outdoor exercise and then take them into a room with 
its windows opened and inside doors closed, and there 
allow them to play for a time. Young infants may be 
wheeled in a carriage or carried in such a room for a short 
time, much to their benefit. 

Clothing. — The way in which a child is clothed has an 
important bearing on his or her health. A child should 
not be overclothed, neither should it be underclad. The 



CHILD HYGIENE 59 

underwear may preferably be of wool-cotton mixture. 
This affords protection and also prevents undue damp- 
ness of the skin which is not healthful. The feet should 
be well covered, the shoes being made to fit the foot and 
not the opposite, which often seems to be the case. The 
condition of the lower extremities is a good index to the 
general warmth of the body. Cold feet should never be 
countenanced. The soles of the shoes should be moder- 
ately thick and tight, but flexible. It has been truthfully 
said that "the best chest protector is a good pair of 
shoes." Enlarged tonsils, repeated' colds" and adenoids 
are very often directly traced to improper covering of 
the feet. All parts of the body should be protected; this 
means the head, legs and chest. 

Body Cleanliness. — During the first six or twelve 
months of life nearly every child receives its daily 
bath, but for some reason or other, after this period this 
state of affairs ceases and a weekly bath is generally 
deemed sufficient. A full daily bath not only removes 
dirt, infectious material and stale sweat, but also tones 
the skin, improves its circulation and renders it more 
potent against external influences, as sudden changes of 
weather, wind and wet. If the child from early years is 
given its morning cool bath, it will become a routine 
procedure and he will look for it as regularly as his 
breakfast, and enjoy it. A cool bath (75°-85°F.) will 
be productive of much good to any child except the most 
delicate, in which case a tepid or warm water bath 
(85°-ioo°F.) may be substituted. 

In order that a cool bath be effective, it must be 
followed by a "reaction," that is, a glowing and warmth 
of the skin. The child may stand in warm water and 
then be sponged with cool water, after which the skin is 



60 FEVER NURSING 

vigorously rubbed with a soft towel to bring about the 
" reaction." If instead of glowing the skin takes on a 
blue tint and the child complains of being cold, it is a 
sure indication that cool baths should not be given, but 
rather a warm wash. 

Under this heading it will not be out of place to refer 
to the condition of the bowels. In nursing or bottle 
infants two or three bowel movements daily are normal 
and in older children a daily movement should occur. 
Insufficient bowel evacuation is a fertile cause of ill 
health and the condition should be remedied. Regular 
habit is the best means of correcting this state of things. 
Daily at the same time, preferably after breakfast, the 
child should be compelled to go to the stool whether he 
has the desire or not, and try for ten minutes to bring 
about the desired effect. A small enema of warm water 
may at times be necessary to stimulate the bowels to act. 

We have considered that one way to prevent ourselves 
from taking disease is to perfectly develop our bodies. 
Another way is to prevent coming in contact with 
disease. Contagious and infectious fevers are spread 
by contact. During epidemics children should be taken 
in street and railroad cars as little as possible and never 
in crowded places, as stores, theaters, moving picture 
shows and such places. A child should be taught never 
to place in its mouth objects which other children have 
had, as lead pencils, gum, and fruit. Kissing of children 
and babies promiscuously is an abomination, if not a 
moral crime. Many an innocent babe or child has 
sacrificed his life for this so-called social act. Diseases 
of all kinds have been spread by this means. The use 
by a child of strange playthings is not without danger. 
The writer has known scarlet fever to be spread months 



CHILD HYGIENE 6 1 

later because an innocent child played with toys which 
were used by a scarlet fever convalescent weeks before. 

The contagious diseases usually gain entrance through 
the mouth and nose. The tonsils, especially if diseased, 
are the main factors. The mouth and teeth should be 
cleansed once or twice daily. Diseased tonsils if they 
exist should be attended to. 

Isolation and Quarantine. — If a contagious disease 
enters the home, your first duty to the community and 
neighbors is to protect them from infection. You 
should bear in mind that the form of scarlet fever or 
measles which your young patient has is no different 
from the same disease in others, and is just as con- 
tagious. Why is it you and others are so opposed to 
quarantine (especially or only when applied to your own 
home)? Why do you and others feel that your liberty 
and rights as citizens are being infringed when your 
home is quarantined? Do you think scarlet fever, 
measles, whooping cough and other like diseases are of a 
trivial nature? If so, let me tell you that in the year 
191 1, in New York state there died of scarlet fever over 
1 147, of measles over 977, of whooping cough over 816, 
of diphtheria over 1961. It will be granted that nearly 
everybody will submit to quarantine for smallpox, yet in 
one year in New York state there were n 44 more deaths 
from scarlet fever than from smallpox. I ask you to place 
a few moments of sound thought on this subject. Think 
what it would mean to the community, state, nation, or 
even yourself and family if contagious infects were 
allowed rampant. Help your local health authorities 
all you can. They are not toiling for themselves but 
for you. Today your home may be invaded by measles 
and you may not wish to be quarantined; tomorrow your 






62 FEVER NURSING 

neighbor may contract smallpox and you will want 
them quarantined. It is necessary to isolate both 
diseases, for in fact more die of measles than smallpox in 
a given time in this country. 

As soon as a member of the family is taken with a con- 
tagious disease he should be isolated from the rest of the 
family in a clean, light, well-ventilated room. All 
intercourse between the patient and others of the 
family should cease. The room should be prepared as 
subsequently explained. Nothing which comes in 
contact with the patient should be used by others until 
freed from infection. 

As nearly all the excretions and external secretions 
from patients ill with infectious disease are capable of 
infecting others, it is necessary that they be rendered 
non-dangerous. The bowel movements and urine may 
be made innocuous by adding to them a small quantity 
of a five per cent, carbolic solution or a i to 500 solution 
of bichloride of mercury. Or you may mix with them a 
quantity of chlorinated lime, or even quick or unslaked 
lime. Then allow the whole mixture to stand an hour 
before throwing out. Excretions from the nose and 
mouth may be received in small pieces of cloth or paper 
and immediately burned, or they may be deposited in a 
cup containing a five per cent, solution of carbolic acid and 
later thrown out. This latter method is not absolutely 
safe, as the patient may by mistake or while stupid get 
some of the poison. The hands may be rendered free 
from poison by immersion in a 1 to 1000 solution of 
bichloride of mercury. The bedclotking, towels and linen 
should be first made safe before sending them to the 
laundry. This may be done by soaking them for three 
hours in a five per cent, solution of carbolic acid. Dishes 



CHILD HYGIENE 63 

used by the patient may be kept in the sickroom and 
there washed, but before returning them to the general 
pantry at the completion of the illness they should be 
thoroughly boiled. When quarantine is about to end, 
the sickroom must be disinfected. 



CHAPTER VI 
ALLEVIATION OF SYMPTOMS 

In this section the medicinal or drug treatment of 
disease will not be considered, it being left to the dis- 
cretion of the attending physician. Only such treat- 
ment will be discussed as a nurse may employ in the 
absence of the physician. Not only symptoms but also 
some of the complications will be given attention. 

Bed sores occur in all diseases in which prolonged 
rest in bed is necessary. They are very common in some 
diseases, especially typhoid fever. 

They are due to interference with the circulation, as 
the result of pressure, and hence the nutrition of the 
skin is cut off, a sore resulting. They occur most fre- 
quently over the bony prominences. Moisture acts as 
an exciting agent; also hard particles on the sheets, such 
as crumbs. Creases in the bed clothing and depressions 
in the mattress tend to aggravate the sores. 

The treatment of this common occurrence is two- 
fold: preventive measures, curative measures. 

Preventive measures must, of course, be used before 
the formation of the sores. Cleanliness is paramount, 
and frequent changes in the position of the patient are 
essential. Do not allow a patient to lie too long in any 
one position. A change of position is restful. 

Hardening of the skin is a most important preven- 
tative. This is augmented by bathing those parts of 

6 4 



ALLEVIATION OF SYMPTOMS 65 

the body where bed sores are usually formed, with vari- 
ous hardening and astringent solutions. Dilute or 
full strength alcohol (not absolute alcohol) are very good 
agents, or a solution consisting of whiskey and common 
salt (1 to 753). Vinegar is very useful. A simple and 
handy way is to take a slice of lemon and rub this over 
those parts that might be affected, repeating daily. 
This will prevent bed sores, when other methods fail. 
Solutions of alum and tannic acid have been used. 

Curative Measures. — After sores have formed active 
treatment is necessary. The sores should first be thor- 
oughly cleansed with a solution of peroxid of hydrogen 
or bichlorid of mercury (1-5000) and then dressed dry 
with some dusting powder, as bismuth subnitrate, aris- 
tol, or stereate of zinc. If the sores show signs of indo- 
lency, touch them with a stick of silver nitrate and 
dress with ichthyol or balsam of Peru. 

Bronchitis. — -In those diseases accompanied by irrita- 
tive conditions of the throat and bronchial tubes it is 
often necessary and agreeable that the air of the sick 
room be moistened. It is not advisable to steam the 
whole room but only that about the patient. To confine 
the steam to this locality a tent is constructed. By 
fastening a stick five feet long to each corner of the crib or 
bed a sheet may form the roof and others the three sides, 
one side being left open. Steam is then conducted into 
the tent from a croup kettle or other improvised genera- 
tor. Have the steam enter at the end opposite the 
patient's head. Oftentimes a medicated steam is more 
useful than plain watery vapor. Creosote, compound 
tincture of benzoin or oil of eucalyptus may be added to 
the water. 

Constipation is the rule in most febrile diseases and 
5 



66 FEVER NURSING 

is due to numerous causes, among which are the prolonged 
rest in bed, the diet of milk, and in some cases the 
medication. 

The constipation is best relieved during the acute 
course of the disease by means of enemata, of which 
there are several kinds. (For the composition of ene- 
mata see that section in the Addenda.) 

Convulsions occur frequently in children ill with in- 
fectious fevers. The very best and rapid method of 
overcoming convulsions is to place the child in a hot 
mustard bath. If the child's temperature be very high, 
this may be the cause of the convulsion. Then cold 
water may be poured over the child while in the bath. 
If there be any reason to believe the attack to be due to 
meningitis, apply ice to the head. 

An enema should be given if the child were previously 
constipated. 

Diarrhea may be very troublesome, especially in 
typhoid fever. Most authorities say that when the 
movements of the bowels number more than six in one 
day, active treatment should be begun. 

In many cases diarrhea can be controlled by applying 
a mustard plaster to the abdomen. In some instances 
it may be necessary to wash out the lower bowel by 
means of a normal saline solution. A rubber tube or 
catheter of large caliber is introduced high in the rec- 
tum and the solution allowed to flow in from a fountain 
bag. Free exit for the returning solution must be 
provided by the introduction of a second catheter of 
smaller caliber than the inflow one. 

Ice water injections have been advocated by some but 
should be reserved for very strong individuals. 

Starch and laudanum enemata. (See Addenda.) 



ALLEVIATION OF SYMPTOMS 67 

Delirium occurs in two forms — the active and the low 
muttering forms. In the former the patient becomes 
more or less maniacal and wild. This is rare in the 
infectious fevers, and as a rule the patient is one who has 
been addicted to the use of alcoholic beverages. 

The active form is combatted by powerful sedative 
drugs. The low muttering form of delirium is best 
treated by hydrotherapeutic measures, as baths, packs, 
etc. ; also by alcoholic stimulation. 

Disorders of the Tongue and Mouth. — In all cases 
of febrile disease careful attention should be paid to 
the mouth, tongue, and teeth. The latter should be 
kept thoroughly clean. The mouth is to be cleansed 
several times daily by swabbing it with cotton or gauze 
wet with some antiseptic solution. A very useful solu- 
tion consists of glycerine, 5 parts; lemon juice, 1 part; 
hydrogen peroxid, 5 parts; water, 25 parts. A solution 
of boric acid or borax may be used or a diluted solution 
of hydrogen peroxid. 

Fever. — See special chapter. 

Headaches are very common in the onset of all 
infectious fevers, and are very annoying to the patient. 
An ice bag applied to the head will relieve the majority 
of headaches. A cold bath or pack are useful in some 
instances. If the bowels are constipated, an enema 
will be of great service. A mustard foot bath often 
gives good results. 

Hemorrhage from the Bowels. — This occurs as a 
complication of typhoid fever in over four per cent, of 
cases. It is a serious occurrence and demands prompt 
and active treatment. The signs and symptoms of 
intestinal hemorrhage are discussed in the chapter on 
Complications. 



68 FEVER NURSING 

The attending physician should be notified at once. 
In the meantime apply an ice-bag to the right iliac 
region of the abdomen; stop all nourishment by mouth 
and enforce absolute quiet. Prepare for giving a hypo- 
dermic of morphine in case the physician might wish it; 
also get the apparatus and solutions ready for giving a 
hypodermoclysis. 

Hemorrhage from the Lungs. — In pulmonary dis- 
ease, especially in ulcerative tuberculosis of the lungs, 
hemorrhage is of somewhat frequent occurrence. 

The treatment is similar to that for hemorrhage from 
the bowels. Place an ice-bag on the chest and prepare 
for a hypodermic of morphine, and for a hypodermoclysis 
if the bleeding has been profuse. 

Hemorrhage from the nose or epistaxis may be very 
severe and persistent in typhoid fever and other infec- 
tious fevers. It is best combatted by first applying 
warmth to the feet by means of hot water bags or a hot 
mustard foot bath. Hot water bags should also be 
applied to the back. Ice, or cloths which have been on 
ice, are applied to the root of the nose. Spray or douche 
the nose with vinegar or diluted lemon juice. Douching 
the nose with very warm saline solution is as useful as 
any method. 

Insomnia is a frequent and very troublesome symptom 
of the infectious fevers. If the temperature be high, a 
sponge bath with cool water or an alcohol rub will relieve 
the feverishness, quiet the nervous system, and be pro- 
ductive of good results. At times a sponge with tepid 
or warm water will be more useful than with cool water. 
A hot foot bath or hot water bottles applied to the feet 
are also good. An ice-bag to the head may be used in 
conjunction with this method, or alone. 



ALLEVIATION OF SYMPTOMS 69 

In many cases a hot drink before the hour of sleep will 
aid in the production of sleep. 

Nephritis occurs often as a sequel of scarlet fever 
and erysipelas (see Complications) and is of grave 
import. The indications are to restore the functionating 
powers of the kidneys and to relieve them of part of their 
duties. This latter is obtained by increasing the 
elimination of water by the skin and bowels. 

Increased elimination of water by the skin is brought 
about by augmenting the excretion of sweat. The 
patient should be placed between blankets with plenty of 
hot water bottles about him. Sweating may also be 
increased by giving the patient a hot air bath. Intro- 
duce under the blanket in which the patient is wrapped 
the end of a tin pipe, the other end of which contains 
an alcohol lamp placed on the floor. (See Fig. 9.) If 
sweating does not occur, it may be hastened by admin- 
istering a drink of cold water. 

When applying heat to an extensive surface of the 
body it is well to have an ice-bag on the head to prevent 
cerebral congestion or heat stroke. 

Plenty of water must be introduced into the system, 
as this aids in the return of power to the kidneys and also 
flushes them of irritating material and toxins. Water 
may be introduced by drinking or by saline infusions 
per rectum or by hypodermoclysis. The bowels should 
be moved by the aid of calomel or epsom salts. 

Hypodermoclysis, or literally, an injection under the 
skin, is one of the most useful procedures in the treatment 
of certain serious and grave conditions. 

The liquid injected is a watery solution of common 
salt, of a determined strength, and is known as a physio- 
logical salt solution, normal saline solution, normal 



JO FEVER NURSING 

salt solution and isotonic salt solution. This solution 
is a 0.6 per cent, to 0.9 per cent, solution of salt (sodium 
chlorid) in water, and is so called because it is of the same 
saline strength as human blood serum. This solution is 
prepared by adding one and one-half drams of common 
salt to one quart of water. The solution must be sterile. 
A more convenient method is to have on hand a sterile, 
concentrated salt solution, and prepare the injecting 
fluid by adding a small amount of the concentrated salt 
solution to one quart of sterile water. The concentrated 
solution is prepared by dissolving six ounces of common 
salt in one pint of water and thoroughly sterilizing it. 
One-half ounce of this solution added to one quart of 
sterile water will produce a normal salt solution. 

The introduction of normal saline solution into the 
system restores the blood serum to the normal amount, 
tones the vasomotor system, stimulates the heart, 
amends the body heat, aids in the elimination of toxins 
and deleterious material through the skin and kidneys. 

The indications for the employment of hypodermo- 
clysis are cardiac failure, especially when accompanied 
by vasomotor disturbances, as in shock, collapse, ether 
and chloroform narcotization, post-operative shock, de- 
pressions during acute diseases, as pneumonia and 
typhoid fever. Loss of body fluids, as in severe hemor- 
rhages and exhausting diarrheas, and in post-operative 
thirst. Toxemias and disease characterized by circulat- 
ing poisons, uremia, etc. Nephritis accompanied with 
anuria. 

Method of Procedure. — Various forms of apparatus 
have been devised with which a saline injection may 
be given. A simple, inexpensive and readily obtainable 
apparatus consists of a quart glass funnel, a piece 



ALLEVIATION OF SYMPTOMS 7 1 

of rubber tubing and a fair-sized aspirating needle; or a 
fountaiu rubber bag, with its tubing, and an aspirating 
needle may be employed. This apparatus should be 
used for no other purpose. The outfit must be absolutely 
sterile before being used. 

The normal saline solution, which should be sterile 
and at a temperature of 103 F., is poured into the 
glass funnel; a stream of the solution is allowed to 
run from the needle until all air is removed from the 
tubing and the solution has warmed the apparatus. 
Between the thumb and index-finger of the left hand 
raise a fold of the patient's skin at the site for the 
injection, preferably below the breasts, the side of the 
abdomen or inner part of the thigh, and with the right 
hand thrust the needle point through the skin at the 
base of the fold into the loose subcutaneous tissues. 
The funnel is elevated about three feet above the 
patient, and the solution allowed to enter the tissues. 
As the parts begin to swell, they should be gently 
rubbed, to diffuse the solution and aid in its absorption. 

After one and one-half pints of the solution have 
entered the tissues the needle is withdrawn and a small 
piece of adhesive plaster applied to the area. 

It is often necessary to repeat the injections one or 
more times. The author has witnessed most excellent 
results from the regularly repeated saline injections. 

Enter ody sis. — The injection of large amounts of 
fluid into the bowel has long been in vogue. It is a 
highly useful method of supplying fluid to the body 
after severe hemorrhage, persistent diarrhea, post- 
operative thirst, and when it is not practicable to give 
water by mouth, in certain stomach disorders. 

In certain forms of nephritis, when the kidneys are 



72 FEVER NURSING 

excreting but little urine, enteroclysis of normal saline 
will often produce very good results. In toxemias, 
diabetic coma, uremia, gas poisoning, acute infectious 
diseases and all conditions characterized by circulating 
poisons, enteroclysis of normal saline will dilute the 
poisons and aid in the elimination. A patient suffering 
from severe toxemia was placed under my charge, in a 
moribund condition. I immediately began to irrigate 
the bowel with normal saline solution, and was soon 
gratified by an improvement in the patient's condition, 
which slowly continued until full return to conscious- 
ness resulted. In six hours I used over fifty gallons of 
saline solution. 

In intestinal diseases, such as dysentery, cholera and 
infantile enterocolitis, enteroclysis of medicated solutions 
is most beneficial. 

In infantile diarrheal conditions, washing of the 
lower bowel will give most gratifying results. 

Method of Procedure. — The saline solution is pre- 
pared as described under Hypodermoclysis. The ap- 
paratus used is the same, excepting that the aspirating 
needle is replaced by a double-flow apparatus of some 
kind. A double-flow arrangement which I have found 
of much service is known as the Martin rectal irrigator. 
The inflow tube is connected with the rubber tubing 
from the funnel or fountain bag, and the outflow tube is 
connected with a piece of rubber tubing leading to a 
waste pail. 

When it is desired that the injection be given high in 
the bowel, a long double-flow tube may be easily 
improvised. A rubber rectal tube with an open end, as 
well as a side eye, and a small-caliber soft rubber catheter 
are necessary. The catheter is passed through the rectal 



ALLEVIATION OF SYMPTOMS 73 

tube until the eye of the catheter projects just beyond 
the end of the rectal tube, and is here secured with a 
stitch of silk. The catheter serves as the inflow tube and 
the rectal tube as an outlet. 

When employing enteroclysis on a child or infant, 
use a soft rubber catheter instead of a rectal tube, and 
secure sufficient outlet. 

The temperature of the solutions used should be 
about ioo° F. 

Rectal Drop Infusion of Saline Solution. — This is the 
introduction into the rectum of a salt solution drop by 
drop. It is one of the most useful procedures in 
child nursing. It is indicated whenever the ex- 
cretion of water by the system is too slow as in certain 
forms of kidney troubles which often occur during the 
acute contagious diseases of childhood. Also in certain 
forms of heart depression it is very necessary. To 
give it a regular rectal fountain syringe outfit with a 
very small nozzle is employed. Around the rubber tub- 
ing leading from the bag a string is so tied that the 
water flows from the nozzle in drops (not in a stream). 
The warm solution (99 F.) is placed in the bag and the 
nozzle is lubricated with vaseline and introduced into 
the rectum. It should take about one-half hour to instil 
one pint of solution. The solution generally used is pre- 
pared by adding a level teaspoonful of common table salt 
to three cupfuls of water. When properly given, very 
little or no solution escapes from the rectum, but is 
absorbed about as fast as it drops in. 

Pains in the back are very troublesome in influenza. 
The application of strong mustard paste, hot water 
bags, or an ice-bag are useful. 

Pains in the joints are the most annoying symptoms 



74 FEVER NURSING 

in rheumatism. The applications for local control of 
joint pains are varied and numerous. Every physician, 
nurse, and housewife has many original painkillers. 
The following are a few of the many and are the 
best: 

A very good application consists in oil of gaultheria, 
one ounce; salicylic acid, one dram, and cotton seed 
oil, twelve ounces. Apply to joint and cover with soft 
woolen cloths and oiled muslin. 

A mixture of equal parts of guaiacol and glycerin 
applied as above is very useful. Ichthyol, either pure 
or as a fifty per cent, ointment. Hot cloths saturated 
with the lotion of lead and laudanum. Chloroform 
liniment is good. 

A most excellent method is the application of an ice- 
bag. The mention of this is disagreeable to the patient, 
but after a few minutes' application the pain becomes 
easier and the patient more comfortable. 

A method used by some physicians is to make woolen 
bags and place a moderate amount of powdered sulphur 
in each and draw them over the affected limb and shake 
them so that the sulphur gets over the surface of the 
limb. Allow the bags to remain on for a few days. This 
method acts better in the subacute cases. 

Peritonitis. — The application of a light ice-bag to 
the abdomen is the best. 

Pleurisy or " Stitch in the side," when it occurs, 
is very annoying to the patient. A hot water bag or 
a mustard plaster placed over the area will generally 
give relief. An ice-bag is fully as good as the hot 
water bag, and in many cases it produces the best of 
results. The application of an ice-bag is repulsive to 
most patients but as they soon learn the great results 



ALLEVIATION OF SYMPTOMS 75 

obtained from its use they do not object after the first 
application. 

Tincture of iodine painted over the area of pain is very 
useful. A belladonna plaster does good in some cases. 

Retention of urine is not of uncommon occurrence 
in the acute febrile diseases, and should not be con- 
fused with suppression of urine. In the former the 
kidneys may be performing their functions normally 
and secreting the proper amount of urine which is 
collected in the bladder, but the patient is unable to 
pass it from this viscus; but in suppression of urine the 
kidney function is disturbed and little or no urine is 
secreted, and the bladder remains free from urine. 
This latter is a very serious condition. 

Before resorting to the use of a catheter in urinary 
retention, other simpler means should be employed. 
Ofttimes retention is of nervous origin, the patient 
being unable to pass urine if the nurse or other person 
remain in the room, but readily accomplishes the act 
if left alone in the room. The sound of running water 
from an open faucet often helps; the application to the 
lower abdomen and genitals of cloths wrung out in 
hot or cold water is often successful in starting the 
flow of urine. Placing hot water in the bedpan, so the 
steam reaches the parts, will sometimes aid. When 
all simple means fail, resort to the catheter is obligatory. 
Of catheters there are two kinds, the rigid and the 
flexible. The rigid are made of metal or glass, and 
the flexible of soft rubber or webbing. 

In catheterization, two things should be ever kept in 
mind: The catheter must be sterile; the patient's parts 
and the nurse's hands must be clean. Rigid catheters 
are sterilized by boiling, and the flexible catheters are 



76 FEVER NURSING 

rendered sterile by immersing for twenty minutes in 
i-iooo bichloride of mercury solution, and thoroughly 
rinsed with sterile water before using. 

The parts of the patient are cleansed with soap and 
warm water and then swabbed with strong boric acid 
solution. 

Catheter fever and cystitis may result from improper 
catheterization. 

If the bladder is greatly distended with urine, it 
should be only partially emptied, as complete removal 
of the urine may bring about collapse. 

Sore throat is troublesome in some of the infec- 
tious fevers, especially in scarlet fever and diphtheria. 
External applications to the throat of heat and cold, 
especially the latter if the patient will submit to it, 
should be used. 

For internal use, that is, as gargles or for swabbing 
the throat, the following are useful: Hydrogen peroxid 
solution (i to 3). Solution of boric acid (1 to 25). 
Tincture of chlorid of iron one dram, glycerine one ounce, 
and water to two ounces. 

Sweating of a profuse type occurs in some cases 
of typhoid fever, usually due to exhaustion or sepsis; 
in tuberculosis pulmonalis and acute rheumatism. 
Sponging the body with the following solution is very 
good: Alum one-half ounce, alcohol two ounces, water 
sixteen ounces. 

A wash of vinegar or of one dram of sulphuric acid 
to one pint of water, is often valuable. 

Tympanites is especially prominent in typhoid 
fever. The abdomen sometimes reaches a great size, 
and the tympanites becomes a very serious complication. 

Intestinal antiseptics administered by mouth aid 



ALLEVIATION OF SYMPTOMS 77 

greatly in decreasing the distention. Of all drugs used 
turpentine stands in the first rank. It should be used 
internally and externally. 

Externally it is used in the form of stupes. For 
instructions on making these see the article on Topical 
Applications. A turpentine enema is of very great help 
in expelling gas. (See section on Enemata.) 

Turpentine used externally is absorbed to a certain 
extent and a continuous use of it may be followed by 
toxic effects. Careful watch must be kept to detect 
the onset of poisonous symptoms. Turpentine is irri- 
tating to the kidneys, and the urine is a means of de- 
tecting its ill effects. The odor of the urine becomes like 
that of violets; later the urine may become cloudy 
and bloody. Cyanosis may occur. In many persons 
it will cause a diffuse, red eruption of the skin. 

Asafetida is very useful in aiding the escape of flatus, 
if given as an enema. (See Enemata.) 

Vomiting is a very distressing symptom and at times 
it seems almost uncontrollable. In many of the most 
severe and protracted cases simple measures have 
brought about the best results. An ice-bag placed on 
the back, epigastrium, or nape of the neck is of service. 
A mustard poultice over the epigastrium works marvels. 
Cracked ice with whiskey or champagne is beneficial. 
Lime water added to the milk relieves the stomach in 
many instances. 

Inhalations from a cloth wet with vinegar, a starch 
and laudanum enema, and washing of the stomach (in 
selected cases) are useful. 

In some cases it will be necessary to temporarily 
stop feeding by the mouth and to rely on rectal alimen- 
tation. (See Enemata.) 



78 FEVER NURSING 

Shock and Collapse.— Below is given a tabulated 
arrangement for the application of remedial measures 
to overcome shock and collapse. 

Elevate the feet and lower the head. 

Apply warmth by means of blankets and hot water 
bags. 

Give diffusive stimulants, as aromatic spirits of 
ammonia, spirits of ether, whiskey or brandy. 

Give stimulants by hypodermic, as strychnine, atropine, 
nitroglycerine, digitalin, and suprarenal solution. 

Amyl nitrite by inhalation is very useful in some 
cases. 

Saline solution subcutaneously or by rectum. 

Rectal injections of a cup of strong, black coffee are 
good. 



CHAPTER VII 
DETECTION OF COMPLICATIONS 

During the course of the infectious fever, complica- 
tions are not only frequent, but in many instances in- 
crease the gravity of the primary disease. They may 
occur during any stage of the disease, from the invasion 
to convalescence. An early knowledge of the onset of 
complications is important, and their detection is only 
accomplished by continued and careful study of the 
patient's condition. A great part of the burden is de- 
pendent on the nurse in attendance, as the complica- 
tions generally make their appearance during the absence 
of the physician. 

The more common complications of each of the in- 
fectious fevers are classified, and then the more im- 
portant complications are discussed in detail. 

Typhoid Fever. — -Intestinal hemorrhage, intestinal 
perforation, bed sores, severe bronchitis, phlebitis, 
grave delirium, excessive diarrhea, cholecystitis, bone 
lesions, pleurisy, pneumonia and septicemia. 

Smallpox. — -Laryngitis, bronchopneumonia, albu- 
minuria, myocarditis, otitis media and iritis. 

Scarlet Fever. — 'Nephritis, arthritis, endocarditis, otitis 
media, meningitis, pericarditis, pleurisy and convulsions. 

Measles. — -Bronchopneumonia, otitis media, laryn- 
gitis, severe bronchitis, paralysis, pleurisy, diarrhea and 
convulsions. 

79 



8o FEVER NURSING 

Mumps. — -Meningitis, nephritis, arthritis, orchitis, 
ovaritis, facial paralysis and otitis media. 

Whooping-cough. — -Pneumonia, nephritis, convulsions, 
hemorrhages into the skin, conjunctivae and from the 
nose and bronchi. 

Influenza. — 'Pneumonia, pleurisy, meningitis, neuritis, 
nephritis and nervous disorders. 

Cerebrospinal Meningitis. — -Pneumonia, arthritis, paral- 
ysis, nephritis, pericarditis, endocarditis and otitis media. 

Lobar Pneumonia. — -Pleurisy, edema of the lungs, 
pericarditis, meningitis, delirium, convulsions and 
empyema. 

Diphtheria. — 'Paralysis, endocarditis, pericarditis, 
pneumonia, nephritis, severe bronchitis, arthritis, otitis 
media and abscesses. 

Articular Rheumatism. — -Endocarditis, pneumonia, 
pleurisy, delirium, meningitis, purpura and convulsions. 

Erysipelas. — Pneumonia, endocarditis, delirium, 
pleurisy, meningitis, pericarditis and septicemia. 

Important Complications 

Arthritis may occur during the course of any of the 
acute infectious fevers, particularly in scarlet fever, 
diphtheria, cerebrospinal meningitis and typhoid fever. 
Any of the joints may be affected. The severity of 
the arthritis varies exceedingly. In scarlet fever I 
have seen instances of involvement of the shoulder joint 
which disappeared in eighteen hours, although at a 
previous visit the symptoms seemed almost unbearable. 
Cases of arthritis of the hip joints following typhoid 
fever, which completely destroyed the joint. The 
inflammation may be of the simple serous type or may 
be suppurative and destructive. One or more joints 



DETECTION OF COMPLICATIONS 8 1 

may be involved. The disease may manifest itself with 
swelling and redness of the parts and great pain and 
tenderness. 

Bed sores may occur during any acute infectious dis- 
ease which prostrates the patient, or during the course 
of which the patient is required to remain in bed for a 
protracted time. Bed sores occur frequently in typhoid 
fever. Bed sores result from pressure or disease of the 
nerves or cord. Pressure acts as an exciting cause in two 
ways — by mechanical damage of the tissues, or by in- 
terfering with nutrition and blood supply of the part. 
The sores first appear as red, glossy areas over bone 
prominences, as the sacrum, ilia, or heels, and may be 
prevented from entering the second stage by removing 
the cause, by the use of astringing and hardening lotions 
and by hydro therapeutic measures (see Chapter V). 
Soon the continuity of the skin is destroyed and an 
abrasion results, which passes into the ulcerous stage 
and may become quite extensive. 

Bronchitis of a severe type is not an uncommon com- 
plication of typhoid fever, measles and diphtheria. In 
typhoid fever this complication is troublesome because 
of the cough, which, when very severe, may urge in- 
testinal hemorrhage. Bronchitis, when complicating 
one of the acute fevers, is recognized by the cough, which 
at first is tight and painful, and later accompanied by 
more or less profuse expectoration. The fever of the 
primary disease may be greatly exaggerated by the advent 
of bronchitis. Chills or chilly sensations are frequent. 

Convulsions occur very frequently in the acute in- 
fectious diseases affecting children, as pneumonia, scarlet 
fever, measles, whooping-cough and influenza. In 
adults convulsions may vary from a slight twitching of 
6 



82 FEVER NURSING 

one member to a general convulsion resembling the 
epileptic seizure with the glottic spasm, rolling eye- 
balls, clenched hands, stiff neck, etc., terminating in 
unconsciousness. 

Delirium may occur in any of the acute infectious 
fevers, and is frequent in typhoid fever, pneumonia, 
erysipelas and rheumatic fever. Delirium is met with 
in two forms — the quiet, low-muttering form, and the 
loud, active form. In typhoid fever the delirium, as 
a rule, is of the low-muttering type. The patient be- 
comes apathetic and semi-conscious, and will pick at 
the bedclothes (carphologia) or attempt to catch imagi- 
nary bodies. The patient may lie unconscious with 
the eye staring, fixed upon one object (coma vigil). 
In rare cases of typhoid fever the delirium may be of 
the active type, the author having seen cases in which 
the patient was very restless, later becoming active, 
wild and noisy, and tried to escape by throwing himself 
through a window. 

Delirium in pneumonia may be of either type, and 
in patients accustomed to alcoholic beverages it may 
become of the character of delirium tremens (mania a 
potu). Delirium is not uncommon in rheumatic fever, 
and may be due to high fever, the action of the toxines 
on the nervous system or to the administration of the 
salicylates (see Chapter XIX). 

Diarrhea. — Diarrhea of ai\ excessive and exhausting 
type ceases to be a symptom and becomes a complica- 
tion. In typhoid fever especially, and sometimes in 
measles, this complication is met. Excessive diarrhea 
exhausts and weakens the patient and prolongs con- 
valescence. 

Edema of the lungs may occur as a complication 



DETECTION OF COMPLICATIONS 83 

in pneumonia or as an antemortem phenomenon in any 
acute infectious fever which has run a severe, exhaust- 
ing and prolonged course. The advent of pulmonary 
edema in pneumonia is of very grave significance. The 
sputum takes on particular character. It becomes 
thin, watery, profuse, pink or blood stained and is 
frothy. Dyspnoea and cyanosis become extreme, the 
facial expression becomes very anxious, the pulse very 
rapid and feeble, and collapse may soon follow. 

Endocarditis. — The toxines formed during the course 
of the acute infectious fevers seem to have a peculiar 
affinity for, and to be capable of injuring, the cardiac 
tissues. In scarlet fever, rheumatic fever, erysipelas, 
cerebrospinal meningitis and pneumonia cardiac com- 
plications are not uncommon. Endocarditis may be 
present without symptom or sign; at other times it may 
be detected only by the physical signs. Subjective and 
objective symptoms may be present as an exaggeration 
of the fever, rapid and irregular pulse, palpitation of the 
heart, precordial discomfort, difficult breathing and 
prostration. 

Intestinal Hemorrhage. — This complication is fre- 
quent in only one of the acute infectious fevers, namely, 
typhoid fever. In the first 137 cases of typhoid fever 
occurring in the Samaritan Hospital which I tabulated 
several years ago, I found ten cases of intestinal hemor- 
rhage (seven per cent. ) . The bleeding may vary from only 
a slight oozing to a profuse hemorrhage. The appear- 
ance of the stool is not always a true index of the severity 
of the hemorrhage. A severe hemorrhage may take place, 
and yet the blood will not appear in the bowel movement 
for some time. Bleeding occurs most frequently during 
the third week of the disease, at which time the sloughs 



84 FEVER NURSING 

of the intestinal ulcers are separating. Intestinal hemor- 
rhages usually occur insidiously, without premonitory 
symptoms. I have had my attention called to a danger 
signal which is said to occur previous to intestinal hemor- 
rhage, i.e., continued paleness of the face. I have not 
observed this sign in a sufficient number of cases to place 
credence on it. The usual symptoms of intestinal hemor- 
rhage are rapid fall of temperature, cutaneous and 
mucous membrane pallor, cold extremities; small, feeble 
and rapid pulse, and, in severe cases, general collapse. 
It should be remembered that the blood does not always 
make its appearance during the stage of active hemor- 
rhage. 

Intestinal Perforation. — Although a rare compli- 
cation, it does occur in typhoid fever. Of the 137 
cases of typhoid fever referred to in the section on 
intestinal hemorrhage, two were complicated with in- 
testinal perforation. This complication is of very 
grave significance, only a very few recovering. It is 
ushered in by sudden and very severe pain in the ab- 
domen, and the signs of collapse, fall of temperature 
to a low point, and a rapid, feeble pulse. Great dis- 
tention of the abdomen predisposes perforation. 

Nephritis is a frequent complication of the acute 
infectious fevers, especially of scarlet fever, diphtheria, 
erysipelas, cerebrospinal meningitis and influenza. In 
scarlet fever, kidney complications seem most frequent 
in the latter part of the third week. The disease 
manifests itself by a diminution in the amount of urine 
voided. The urine is of a high specific gravity, dark 
in color (it may be of a "smoky" or "briny" color) and 
contains much albumen. There is usually edema of 
the skin, appearing first in the lower eyelids, and may 



DETECTION OF COMPLICATIONS 85 

later become general. Lumbar pains, vomiting and 
signs of gastro-intestinal disorders may occur. In the 
severe cases uremic signs are apt to be manifest. 

Otitis media, or middle-ear disease, may complicate 
scarlet fever, diphtheria, cerebrospinal meningitis, 
measles and mumps. The affection is characterized 
by ringing in the ears, dizziness, difficulty of hearing, 
pain, discharge and febrile disturbance. 

Paralysis. — Various forms of paralysis may com- 
plicate the acute fevers. In diphtheria they are not 
infrequent. Paralysis of the muscles of the palate is 
common and causes regurgitation through the nose of 
fluids and small particles of food on attempting to 
swallow. A characteristic nasal twang is produced. 
Paralysis of other muscles may occur — as the facial, 
ocular, laryngeal, humeral, etc. In cerebrospinal men- 
ingitis, not only may the muscles of the eye, tongue 
and larynx be paralyzed, but even the arm or the whole 
of one side of the body. 

Pericarditis may occur in scarlet fever, pneumonia, 
erysipelas, rheumatism and cerebrospinal meningitis. 
The onset of pericarditis does not depend on the extent 
or severity of the primary disease. The author has 
reported a fatal pericarditis with effusion complicating 
a mild case of pneumonia with consolidation no larger 
than a silver dollar. The signs of pericarditis are 
exaggeration of the fever, precordial distress, cough, 
difficulty of breathing, palpitation and a rapid, weak 
pulse. 

Phlebitis and the formation of thrombi in the veins 
occurred in four of the 137 cases of typhoid fever re- 
ferred to above. In one instance it formed on the sixty- 
sixth day of the disease. There is pain and tenderness 



86 FEVER NURSING 

at the site of the phlebitis, and the vein may feel like 
a hard cord. The parts below become swollen and 
edematous. The thrombosis occurs, as a rule, in the 
left femoral vein. If the artery is involved, gangrene 
will likely follow. 

Pleurisy in pneumonia should be considered as a 
symptom rather than a complication, for it occurs in 
all cases where the surface of the lung is involved. 
As a complication it is seen in rheumatic fever, influenza, 
typhoid fever, measles and scarlet fever. Signs of the 
onset of pleurisy are sharp, stabbing pain in the chest, 
especially when coughing or taking a deep breath, 
chills or chilly sensations, suppressed, dry cough and 
dyspnoea. 

Pneumonia, when complicating the infectious fevers, 
is usually of the catarrhal or bronchial type, and is 
encountered most frequently in erysipelas, influenza, 
measles, rheumatic fever, whooping-cough and cerebro- 
spinal meningitis. Pneumonia is a very serious com- 
plication, and when affecting a debilitated person 
suffering from one of the acute fevers it is very apt to 
prove fatal. This is especially the case in measles. 
The onset of this complication is accompanied by 
irregular, high fever, great prostration, cough, cyanosis, 
difficult breathing, chills and a very rapid pulse. 

It may be said that when one disease complicates 
another, the course of the complicating disease is not 
only often irregular, but may be completely concealed 
by the primary disease. 



PART II 

SPECIAL DISEASES 

CHAPTER VIII 
TYPHOID FEVER 

Synonyms. — 'Enteric Fever, Abdominal Typhus, 
Autumnal or Fall Fever. 

Etiology. — 'The causes of typhoid fever are divided 
into two classes — predisposing and exciting. 

The onset of an acute infectious disease depends on 
two factors, namely, the resistance of the individual 
and the virulence of the bacteria and their products. 
If the resistance of the person be lowered by exposure 
to cold and damp, to poor food, etc., then the specific 
bacteria, if they gain entrance to the body or are present 
in the body, can easily propagate because the resistance 
or vitality of the person is not great enough to stand 
the attack of the micro-organisms; consequently disease 
ensues. On the other hand, if the resistance of the in- 
dividual be high, that person may even withstand the 
attack of very virulent germs. 

If no germs of a certain disease are present or if 
they do not gain entrance to the individual, no matter 
how low his resistance may be he will not contract that 
disease. 

The onset and severity of the course of an acute 
infectious disease depend on the degree of resistance 

87 



88 FEVER NURSING 

of the person and the virulence of the infective micro- 
organisms. 

The predisposing causes of typhoid fever are Fall 
season and adult life — 'typhoid fever occurs but rarelv 
in the very young or aged. Males and females are 
about equally susceptible. 

The exciting cause is the bacillus of Eberth and 
Koch, or the Bacillus Typhosus. This bacterium has 
great powers of resistance. The bacillus retains its 
vitality for some time even if heated to 140 F. (dry 
heat), but will not withstand the same amount of moist 
heat. It lives even in ice. 

The bacilli gain entrance to the body in many ways, 
but the principal means of ingress are by food and 
drink. Drinking water probably forms the most fre- 
quent mode of entrance. The small creeks and streams 
leading into the water supply of cities are a source of 
infection. These small streams derive their virulence 
from contamination with the excreta of infected persons. 
The excretions, even if thrown on the ground or buried 
some distance from the stream, are dangerous and 
may contaminate the water by percolating through 
the ground or being washed in by heavy rains or by 
the freshets in the Spring. 

Ice taken from ponds or places contaminated with 
the bacilli is dangerous. Food infected by polluted 
hands, by exposure to impure air, or by infectious 
material carried by flies and insects is a source of the 
disease. 

Vegetables and fruits handled by unclean hands or 
washed with contaminated water are another source. 
Milk derives its infective character from polluted hands, 
or from infected water used either to adulterate the 



TYPHOID FEVER 89 

milk or to clean the pans and cans into which the milk 
is placed. The germs may also drop in from the air 
which has been contaminated by the secretions of man 
or animal. 

Oysters are said to be a carrier of the infection. 
They derive their virulence from sewerage which is 
deposited into the water near the oyster beds. Clothing 
and bedding become contaminated by drying dejecta. 
Human beings may act as bacilli carriers, and many 
instances of such have been recorded in medical litera- 
ture. After an attack of typhoid fever, the germs 
may be found in the bowel movements and urine for 
months, even years, and thus the individual becomes 
a menace to public health for a prolonged time. Other 
persons who themselves have never suffered an attack 
of typhoid fever, but have been in contact with the 
patients, may retain the bacilli and impart the disease 
to others. Flies are found to be a frequent means of 
disseminating the disease. This has been repeatedly 
demonstrated to be the case, especially in the Hispano- 
American conflict, when flies would travel from the 
excretion trenches to the cook tents and kitchens, thus 
infecting the food of the troops. 

From what has been said of the cause of typhoid 
fever it will be seen that much can be done to prevent 
this disease. Only such water as is perfectly pure 
should be used for potable purposes. If there be any 
doubt, the water should be boiled well and cooled by 
placing ice around the receptacle holding the water 
and not in the water. To prevent the spread of the 
disease everything which comes in contact with the 
patient should be thoroughly disinfected after its use. 
Windows, not only of the sickroom but of the house, 



90 FEVER NURSING 

should be thoroughly screened. The excretions of the 
patient should be so covered that they are not accessible 
to flies. 

The excretions from the bowels and the urine should 
be collected in vessels containing some disinfectant, as 
carbolic acid (i to 20) or bichlorid of mercury (1 to 
1000). Do not use the bichlorid of mercury in metallic 
dishes. Before throwing the excretions away they 
should be mixed well with chlorinated lime or a strong 
solution of copper sulphate, and allowed to stand for 
a short time. 

Bedclothing should be soaked in bichlorid of mercury 
solution or carbolic acid solution before washing. Gauze 
or handkerchiefs used to collect the nasal and pharyngeal 
secretions should be burned. A separate set of dishes 
should be used for the patient. 

Wash the perineum and surrounding skin with some 
antiseptic solution after each bowel movement. 

Clinical Symptoms. — The disease is gradual in its 
onset. The prodromal symptoms are lassitude, malaise, 
loss of appetite, headache, especially of the frontal 
type, dizziness, insomnia, slight cough, pain in the nape 
of the neck, catarrhal conditions of the nose and throat, 
nose bleed, vague pains, and often slight diarrhea. 

Temperature.— The fever rises gradually with a step- 
like curve with daily remissions of one-half to two 
degrees, and reaches its height usually in seven to fourteen 
days. After reaching the fastigium the temperature 
remains there with but slight diurnal remissions for 
a period of about one week when it begins to decline 
with marked daily remissions. The temperature gener- 
ally reaches the normal at the end of the third week or 
the beginning of the fourth week. 



TYPHOID FEVER 



9 1 




92 FEVER NURSING 

A temperature of io3.5°-io4.5°F. is the average in 
the second week of typhoid fever. If the fever persist 
at io5°F. for any length of time, it is serious. A con- 
tinued high temperature may be due to some compli- 
cation as otitis media, pneumonia, etc. A sudden fall 
in temperature may be due to intestinal hemorrhage 
or perforation of the bowels. In the decline of the 
fever a sudden rise may be due to the onset of some 
complication, to constipation, an error in diet, or mental 
emotion. 

Spleen. — -The spleen as a rule is enlarged. The en- 
largement is generally perceptible at the end of the first 
week and disappears in the second or third week. A 
persistently enlarged spleen is said to be indicative of a 
relapse. 

Countenance. — 'The face is at first flushed and the 
eyes bright; later the patient becomes listless and the 
expression dull. 

Eruption. — This occurs at the end of the first week. 
It appears in crops lasting from one to four days. Its 
presence is especially noticeable on the front of the 
abdomen and chest as a rose-red papular eruption, 
which disappears on pressure. 

Tongue. — -The tongue at first is only slightly coated 
and is moist. As the disease progresses there is a tend- 
ency for the tongue to become dry, and in severe cases 
a dry tongue with numerous deep cracks is not an 
uncommon occurrence. The tongue is protruded very 
slowly, due to the apathetic condition of the patient. 

Stools.— The bowel movements in over fifty per cent, 
of cases are of a yellow ochre color and are called pea 
soup stools. The odor is very foul and more or less 
characteristic. 



TYPHOID FEVER 93 

Tympanites or distention of the abdomen occurs to 
some extent in nearly all cases of this disease. It may 
reach an alarming degree and interfere with the action 
of the heart and lungs. 

Respiratory Tract. — 'Bronchitis of varying degrees 
is a very frequent accompaniment of typhoid fever. 
Pneumonia may occur in the course of the disease or as 
a complication. 

Circulatory System. — The pulse during the first week 
varies from 75 to 85 and is in proportion to the rise of 
temperature. Later in the disease the rise of tempera- 
ture is greater than the advance in the pulse rate. A 
pulse rate of 120 in the second week of typhoid fever, 
if not due to a complication, is said to be a signal of 
danger. The pulse is often dicrotic after the first stage 
of the disease. Pericarditis and endocarditis are rare 
complications of typhoid fever. 

Thrombosis of the vessels, especially those of the 
thigh, is not uncommon. Gangrene of the extremity 
may follow. 

Digestive System. — -Tongue (see above). 

Diarrhea occurs in fifty per cent, of cases, and if a 
purge be given, excessive catharsis may follow. 

Vomiting is not common, but does occur in the third 
week, due to an error in diet, perforation of the bowels, 
or local peritonitis. 

Sordes of teeth and lips is an accumulation of food, 
micro-organisms and epithelia. 

Hemorrhage or perforation of the bowels may occur. 
For a description of these see the section on Detection of 
Complications. 

Musculature. — -The muscles diminish in size and be- 



94 FEVER NURSING 

come flabby. Emaciation is rapid in cases associated 
with diarrhea. 

The urine is diminished in amount, is highly colored, 
specific gravity is raised, urea is diminished, and albu- 
men may be present in small quantities. In some cases 
the urine is greatly increased in amount and of a light 
color. The Ehrlich diazo reaction may be present, a 
description of which may be found in more exhaustive 
works. 

Nervous System. — Delirium occurs in a large per- 
centage of cases, and may be of the active or noisy 
type, or the low-muttering form. The latter is more 
common. It occurs in the second or third week. The 
patient becomes stupid, mutters to himself, may pick 
at the bedclothes (carphologia). A twitching of the 
wrists, etc., is often present (subsultus tendinum). 
The patient may lie with the eyes widely open and stare 
in one direction for some time (coma vigil). 

Convulsions may occur in the young. 

Other symptoms which may occur are deafness, bed 
sores, sweats, boils, jaundice, laryngitis, hypostatic 
congestion of the lungs, neuritis, nephritis, bone lesions 
and arthritis. 

Diagnosis. — This can usually be made from the 
several days of malaise, frontal headache, slight cough, 
loss of appetite, nose bleed, rose rash, and enlarged spleen, 
together with the temperature characteristics. 

Typhoid fever may be confused with acute miliary 
tuberculosis, gastro-intestinal disorders, auto-intoxica- 
tion, cerebrospinal meningitis, pneumonia, remittent 
fever, secondary syphilis, bronchitis in children, ulcera- 
tive endocarditis, influenza, trichinosis, appendicitis, 



TYPHOID FEVER 95 

septic processes, typhus fever, articular rheumatism, 
and abscess of the liver. 

For the Widal reaction see section on Bacteria in the 
Addenda. 

Prognosis. — The prognosis depends greatly on the 
treatment. The institution of baths in the treatment 
of typhoid fever has greatly reduced the rate of mortality. 
A more or less persistent temperature of 105 in the first 
week is grave. A pulse of 120 or over is serious. 

Diarrhea does not seem to have any effect on the 
prognosis unless it be exhausting. 

Marked tympanites may cause pulmonary compli- 
cations and may portend perforation of the bowels. 
Hemorrhage is weakening. Perforation is very serious. 
Severe nervous symptoms are serious. 

Care and Management. — Prophylactic measures are 
of utmost importance in combating the spread of typhoid 
fever. The nurse being in constant attendance will play 
the chief role in preventing the propagation of the disease 
to other members of the patient's family or to the 
individuals of the community. 

The water supply, as has already been indicated, is 
the chief source of danger. All water used by the 
patient and the family should be of a known purity. 
If it be impossible to get an absolutely pure spring 
water, then the regular drinking water may be used, 
but it must first be made danger-free. This can be very 
easily accomplished by boiling. The water should be 
boiled vigorously for fifteen minutes and then allowed to 
cool. 

Do not place ice in the water after it has been boiled, 
for in doing so the water is rendered liable to infection. 
The proper way of cooling the water is to place the 



96 FEVER NURSING 

pitcher or receptacle tilled with water into a larger dish 
or pan, and then surround the pitcher with cracked ice. 
In this way you prepare iced water and not ice-water. 

Milk is another source of danger and unless known 
to be absolutely free from infection should be rendered 
so. Milk may be either sterilized or pasteurized. 

To sterilize milk it must be kept at the boiling point 
(2i2°F. or ioo°C.) for fifteen or twenty minutes. 
Sterilization of milk renders it less digestible, precipi- 
tates the albumen and partially destroys the fat emulsion. 

Pasteurization is to be preferred if the milk is to be 
used within twenty-four hours. This is done by raising 
the milk to a temperature of i55°F. or 68°C. for thirty 
or thirty-five minutes and then rapidly reducing the 
temperature to 5o°F. or io°C. Place in the refrigerator, 
ready for use. Pasteurization destroys the germs but 
does not produce the changes in milk that sterilization 
at the boiling point does. 

We have considered the methods of preventing the 
spread of typhoid fever from outside sources; now 
let us consider the dangers of infection from the patient 
himself. 

All secretions and excretions of a typhoid patient 
may be a source of infection, some to a greater degree 
than others. 

First, we have the secretions from the nose and throat. 
These are usually collected on handkerchiefs. It is 
better to use for this purpose pieces of old muslin or 
linen. The cloths after being used by the patient should 
be burned and not washed. Expectoration should be 
expelled into small pieces of tissue paper and immediately 
destroyed by fire. 

Clothing. — 'The undershirt and gowns which are 



TYPHOID FEVER 97 

contaminated by perspiration and possibly by urine, 
should be thoroughly soaked in ten per cent, solution of 
carbolic acid before they are washed and boiled. 

The urine and feces are a most dangerous source of 
infection. The urinals and bedpans should contain some 
antiseptic, as ten per cent, carbolic acid solution, solution 
of copper sulphate, chlorinated lime; if the vessels are 
not metallic, a i to 500 solution of the bichlorid of 
mercury should be used. The antiseptic should be 
placed in the vessel before and not after using. Thor- 
oughly mix the excretive matter with the antiseptic and 
allow it to stand for a while before emptying it out. In 
the country and in houses not connected with a sewer 
system, the excretion should not be thrown into the 
privy vault, but into deep trenches, dug some distance 
from wells and cisterns and where the natural grade of 
the ground is away from the water supply and creeks or 
ponds. The trenches should be three feet deep and 
provided with a cover. They should have a bottom of 
three inches of unslacked lime. The excreta should be 
disinfected before being emptied into the trench. Lime 
should be sprinkled in after each load of excreta. The 
trench should not be filled with excreta, but be covered 
in with lime and earth when half filled, and another 
trench dug. 

Diet. — -What should constitute the diet during the 
course of typhoid fever is a much debated question. 
Although many diverse statements have been made on 
this subject, nevertheless, according to the majority of 
physicians, milk forms the basis of diet. 

At least four ounces of milk should be given every 
two hours. If whole milk does not agree with the 
patient, it should be diluted with plain sterile water, 
7 



98 FEVER NURSING 

limewater or Vichy. Water should be given freely, but 
it cannot take the place of milk. 

The author has found a very valuable diet during the 
acute stage of typhoid fever to be one which is partially 
based on the caloric value of foodstuffs. The patient 
is to receive an eight-ounce feeding every two hours from 
8 A. M. to 8 P. M., and then is placed on a four-hour 
schedule until 8 the next morning. The diet consists of 
two parts — -the milk mixture and the carbohydrate mixture — ■ 
which are to be given alternately. The milk mixture 
consists of six ounces of whole milk, into which is 
thoroughly beaten the white' of one egg, and then one 
teaspoonful of milk sugar is to be added. The balance 
of the eight ounces is to consist of plain water, or equal 
parts of water and limewater. The carbohydrate mix- 
ture consists of eight ounces of farina gruel or cream- 
of-wheat gruel, made as directed in the recipes found in 
Chapter III, using a teaspoonful of milk sugar to each 
feeding. As the disease progresses toward convalescence 
the whole egg, instead of the white only, may be em- 
ployed in the milk mixture. If it be considered neces- 
sary, spiritus frumenti or spiritus vini Gallici may be 
added to each feeding of the milk mixture. 

Other articles of diet which the author has found 
valuable, and which break the monotony, are clam milk, 
oyster milk, ice cream and junket. 

Lemonade, weak tea and coffee are allowable. Beef 
tea, beef broth, some form of predigested beef, gelatin, 
egg-albumin water and barley water may be given, 
depending on the physician's orders. For the prepara- 
tion of these articles of diet see Chapter III. 

No solid food is to be given until the temperature has 
been normal for at least ten days. 



TYPHOID FEVER 99 

The medicinal treatment of uncomplicated cases of 
typhoid fever amounts to almost nothing. Recovery 
depends mainly on general measures and good nursing. 

Fever. — The reduction of temperature by means of 
drugs in typhoid fever is almost obsolete. The physi- 
cians of today depend nearly entirely on hydropathic 
measures. A nurse to be thoroughly proficient must 
know not only how to apply the different means of 
reducing fever without the aid of drugs, but must also 
know their relative value and indications. 

When the temperature is moderate (io3°F.) cold 
baths need not be given. The regular daily cleansing 
bath together with proper ventilation, light bedclothing, 
and cooling drinks are all that are necessary. 

When the fever rises above io3°F. more vigorous 
means are demanded. Cold sponges, alcohol rubs, cold 
packs, and cold tub baths are the more common methods. 
For details of these see Chapter IV. 

The systematic use of baths has greatly reduced the 
mortality in typhoid fever. Applications of cold not 
only reduce the fever but accomplish equally if not 
more important other results, as quieting delirium, 
overcoming insomnia, steadying the pulse and heart, and 
improving respiration. 

It was said at one time that baths were contra- 
indicated in hemorrhage and perforation of the bowels. 
It has been established that hemorrhages do not contra- 
indicate the giving of cold baths. 

Plenty of water given internally also tends to lower 
the temperature by inducing sweating, thus losing 
heat by evaporation and through abundant hot urine. 

There is one important condition which necessitates 
abstention from giving baths, and that is a weak heart. 



IOO FEVER NURSING 

When cold is first applied to the body the surface 
capillaries are generally contracted, the arterial tone 
is raised, and the blood accumulates in the deep organs. 
This places a sudden and extra labor on the heart and 
may cause dilatation and sudden collapse. 

The use of external cold in the form of sponges, 
packs, etc., as an antipyretic measure is usually insti- 
tuted when the temperature reaches io3°F. It is 
important that the temperature be not reduced lower 
than ioo.5°F., because after the completion of the bath 
the temperature usually falls a degree or more. If the 
temperature be kept above the normal there is no 
danger, but great care must be taken because when the 
temperature is reduced below ioo°F. it at times falls 
very rapidly and collapse may follow. 

In applying cold by any method surface reaction is of 
prime importance. In order to obtain this, constant 
and somewhat vigorous friction and rubbing are neces- 
sary. During the procedure the patient is not to be 
allowed, under any circumstances, to exert himself. 
He is to be absolutely passive, as conservation of heart 
energy is a most important object. It is very seldom 
necessary to give more than six baths in a day. The 
patient is exhausted when the baths are too frequently 
given and they become a source of harm rather than of 
benefit. The writer left word with the nurse on one of 
his typhoid cases that she should give the baths at such 
times as she thought necessary. The next morning the 
patient was in a more or less exhausted condition. The 
nurse on being asked how many baths were given since 
the last visit, which was the day before, replied eighteen. 
This accounted for the great weakness of the patient. 

Bed Sores. — These common occurrences are first to 



TYPHOID FEVER IOI 

be prevented from forming; if this be impossible, then 
measures must be adopted to induce rapid healing. 

To prevent them two objects are to be accomplished 
— removal of pressure against the parts, and hardening 
of the skin. The first is brought about by frequent 
changes in the position of the patient or by interposing 
some cushion between the parts pressed upon and the 
bed. For this purpose the rubber pneumatic ring or 
large pads of cotton may be used. 

To harden the skin, bathe the parts with alcohol or 
paint them with a mixture of aloes and glycerine. (Take 
one ounce of the tincture of aloes and heat it until it is 
evaporated to one-half ounce. While it is evaporating 
add gradually six ounces of glycerine.) A most efficient 
means is to rub the parts with a fresh slice of lemon. 
Applications of salt and whiskey are good (salt, one 
dram; whiskey, eight ounces). 

When the sore is formed the above measures are 
useless. The sore must be kept very clean, preferably 
by syringing with peroxid of hydrogen and then rinsing 
with sterile water. Some ointment, as twenty-five per 
cent, ichthyol ointment, should then be applied. 

The mouth should be kept scrupulously clean. A 
very good mouth wash is prepared as follows: Boric 
acid, one dram; juice of one lemon; glycerine, one ounce; 
and water to make four ounces. A i to iooo solution 
of potassium permanganate makes an excellent wash. 

Nausea and vomiting, although rare in typhoid fever, 
may occur. A mustard plaster placed over the pit of 
the stomach or an ice-bag on the epigastrium are very 
useful. Limewater added to the milk will be successful in 
many cases. A measure which is easily applied and 
often works well is the inhalation of vinegar fumes. 



102 FEVER NURSING 

Diarrhea is very common. When the bowel move- 
ments number more than six in twenty-four hours, active 
measures must be taken to stop the diarrhea. Enemata 
of starch paste and laudanum, together with a mustard 
paste applied to the epigastrium, are very useful. 
Meat juices and broths should be discontinued if they 
are being given, as they often cause the diarrhea. The 
diet should be reconsidered; probably the patient is 
receiving too much milk or milk not sufficiently 
diluted. 

Tympanites is a common and at times a very trouble- 
some symptom. It is due to fermentation in the bowels, 
to paresis of the muscular coat of the intestines, or to a 
combination of both. If due to fermentation, intestinal 
antiseptics, such as salol, thymol, sulphocarbolates, 
etc., and evacuation of the fermented material by means 
of laxatives or enemata are indicated. If due to slug- 
gishness or paresis of the bowels, an intestinal tonic or 
stimulant, as turpentine, is indicated. Turpentine is 
the best drug we have for relieving the tympanites. 
It may be used in three ways: internally, about which 
the attending physician will give instructions; by rectum; 
locally to the abdomen as stupes. 

Asafetida as an enema is also very useful in expelling 
gas. (See Chapter XXVIII for instruction in preparing 
enemata and stupes.) 

Constipation. — The bowels should move at least once 
a day. After the first week it is advisable not to use 
cathartics but to resort to enemata. Enemata of soap 
suds, glycerine and water, cotton-seed oil, or the purgative 
enema may be used. (See Chapter on Enemata.) 

Epistaxis, if it persist or be profuse, should be treated. 
Douching the nose with plain hot water, or hot water and 



TYPHOID FEVER IO3 

vinegar, is useful. Spraying the nose with a 1 to 1000 
solution of adrenalin chlorid is useful. 

Delirium is best combated by cool sponges and baths. 
Opium in the form of Dover's powder is beneficial if a 
sedative be necessary. 

Hemorrhage and Perforation. — See Chapters V and 
VI, Part I. 

Care in Convalescence. — During this period care 
as great as, if not greater than, that during the general 
course of the disease is necessary. As convalescence 
advances the visits of the physician become less and less, 
the responsibilities of the nurse become greater and 
greater. It is at this time that the patient regains that 
which he had lost during the run of the disease, as blood, 
fat, muscular tissue, nervous and mental energy. 

The dangers of convalescence are many. The patient 
acquires a ravenous appetite and demands a greater 
amount of food and even makes threats as to what he will 
do if an increased amount of diet be not oncoming. 
Great vigilance on the part of the nurse is necessary. 

Solid food should not be given until the temperature 
has been normal for ten days; in the meantime the diet 
can be varied with eggs in different forms, cereals, jellies, 
gruels, toasts, etc. Perforation of the bowels has 
occurred late in convalescence due to the eating of a 
meat chop. 

A rise of temperature during convalescence may be 
due to a true relapse, which as a rule pursues a shorter 
and milder course than the general attack; or it may 
simply be a recrudescence due to constipation, an error 
in diet, or to mental excitement. A visit from an un- 
welcome person may send the fever very high. 

The patient should at first sit up in bed for a short 



104 FEVER NURSING 

time daily, then should sit up in bed to eat his meals 
and later to read or to receive visitors. As he gains 
strength he may sit in a chair for a short time, but 
should not receive visitors during the first few seances. 
Walking about the room, first aided and later unaided, 
should be gradually undertaken. 

Paratyphoid Fever 

From the experience of the author, it seems proper 
that this disease be considered under a separate 
description. Owing to its similarity and confusion with 
typhoid fever, it is best described here. The author's 
recent writing* is freely employed. 

Historical. — Over 300 cases of this affection have 
been reported in literature, which have followed a 
course resembling that of typhoid fever, but in which 
the causal element was found not to be the bacillus 
typhosus. Archard, in 1896, described the first two 
cases of paratyphoid fever, and isolated a bacterium 
differing in many ways from the typhoid bacillus. In 
rapid succession, cases were reported and the bacillus 
studied by Widal, Cushing, Jurgens and others. 

Etiology. — The bacillus paratyphosus belongs to the 
genus Typhocolon. It stands between the colon bacillus 
and the typhoid bacillus, probably in closer relationship 
to the latter. Of the members of this family, the 
bacillus coli communis and the bacillus typhosus are 
diametrically placed, with the members forming mid- 
groups, the paratyphoid bacillus closely approximating 
the bacillus typhosus, whereas the bacillus of Gaertner, 
or the bacillus of meat poisoning, which also is closely 

* N. Y. Med. Journ., xcii, p. 809. 



TYPHOID FEVER 105 

related, is placed nearer the bacillus coli. The bacillus 
paratyphosus differs from the bacillus of typhoid fever 
in that the former is shorter, more slender, less flagel- 
lated and more motile. It also is unlike in certain 
cultural properties. From the bacillus coli it is dis- 
tinguished by its failure to produce indol. 

Prodromes. — The onset of this disease is generally 
of brief duration and somewhat abrupt. The patient 
who was in former good health is soon complaining 
of various muscular and so-called bone pains. Stiff- 
ness of the neck has been a very prominent symptom 
in this series of cases. Chills are not common, but 
the occurrence of chilly sensations and more or less 
profuse sweating are not infrequent. Sore throat, 
severe headache, pain in the "pit of the stomach" are 
ofttimes present. This short prodromal period of 
from three to five days' duration contrasts markedly 
with the long-drawn, insidious onset of typhoid fever 
with its malaise, anorexia and insomnia. 

Symptoms. — The general symptoms of the disease 
are of early advent. The patient may present an 
anxious and flushed appearance for the first few days 
and stupidity may exist in a mild form, but in the 
writer's cases these signs soon disappeared and the 
patients became extremely bright and placid, troubled 
not in the least with insomnia. In severe cases, great 
dulness of intellect and delirium may occur. The 
headache of the prodromal period, which is rather a 
pain (cephalalgia) than an ache, soon lessens and dis- 
appears. The alimentary symptoms are to a certain 
extent characteristic. The tongue, which in typhoid 
fever is early swollen, thickly coated and tremulous, 
and later dry and fissured, in this disease remains 



io6 



FEVER NURSING 



moist throughout, is of normal size and only lightly 
coated. Sordes do not tend to collect. The appetite 
is usually blunted in the early stage, but rapidly re- 
turns, even before the fever has desisted. Redness of 
the pharynx and painful swallowing, which may have 
been pronounced in the prodromal state, become less 
and pass away. Nausea and vomiting are of frequent 




Fig. i] 



-Temperature chart of a case of paratyphoid fever, showing the 
oscillations of fever. 



occurrence in the early days of the disease. The in- 
testinal condition is quite typical. Although diarrhea 
does occur, it is not the rule, and constipation is much 
more frequent. In the writer's cases the evacuation of 
formed feces throughout the course of the disease was 
characteristic. Tympanites of great degree is not 
common, although slight abdominal distention does 



TYPHOID FEVER 107 

occur but, as a rule, is not troublesome. The spleen 
is usually enlarged; even if not palpable, it may be 
revealed by percussion. The liver is found enlarged in a 
great percentage of cases. Intestinal hemorrhage is not 
frequently met with. It occurred in only one of the 
author's cases. 

The febrile manifestation is extremely characteristic. 
High fever may occur in the early stage, and the fas- 
tigium is rapidly reached. The diurnal remission 
of temperature is a very pronounced and indicative 
sign. From the beginning of the disease the fever 
may remit daily, very often to normal. The fall of 
temperature is frequently as much as 4 or 5°F. The 
accompanying chart, which is quite typical of all the 
cases of this series, distinctly shows this oscillation of 
temperature. The fever, which in many instances is 
of shorter duration than in typhoid fever, may con- 
tinue for an extended period. In one of the writer's 
patients the febrile period lasted thirty-nine days. The 
decline may take place by crisis or lysis. 

The skin may present a roseolar eruption which 
occasionally is typhoid-like, or more often as dark, 
blotchy lesion with tendency toward confluence. Sweat- 
ing may be marked in the early stage. The pulse rate 
is slow, compared to the degree of fever present, and 
may take on a dicrotic quality. 

Complications of a purulent nature seem to be not at 
all uncommon, arthritis, otitis, osteomyelitis and parot- 
iditis being the most frequent. Intestinal hemorrhage, 
if it occurs, is not alarming. Perforations of the bowels 
I have not seen reported in literature. 

But little can be said of the prognosis in paratyphoid 
fever, for reason of the limited number of cases reported 



108 FEVER NURSING 

in literature. As a rule, the course of the disease is 
shorter and milder than that of typhoid fever. In 
some instances the duration of the affection has been 
twelve weeks or longer. Convalescence may be very 
tardy and relapses are not uncommon. Complications 
are frequent. The mortality in reported cases has been 
about three per cent. 

Diagnosis. — The diagnosis of paratyphoid fever is 
of most import to us. The clinical course of the disease 
bears a close resemblance to that of typhoid fever, 
and it may be absolutely impossible to distinguish the 
two diseases clinically. There are, however, certain 
points of dissimilarity. The abrupt onset, the short 
prodromal period, the marked diurnal remission of 
temperature, the blotchy eruption, the moist tongue and 
the bowel condition of paratyphoid fever will greatly 
aid diagnosis. The surety of diagnosis must, notwith- 
standing, rest on bacteriological methods. The re- 
peated absence of the Grueber-Widal reaction is of 
utmost importance. Gwyn has said that this reaction 
is found in 99.6 per cent, of all patients suffering from 
typhoid fever; hence its constant non-appearance, or its 
occurrence only in low dilution (1 to 10 or 1 to 5), in 
a typhoid-like disease is very suggestive of paratyphoid 
fever. The finding of a paratyphoid agglutination is 
typical and may occur in dilution as high as 1 to 6000. 
The most conclusive evidence, however, is the isolation 
of the bacillus from the patient's blood. 

Very few instances of necropsic examinations are 
recorded; therefore, our knowledge of the morbid 
anatomy of this affection is limited and very incom- 
plete. Intestinal lesions have been described in the 
form of slight ulceration, but the Peyer's patch and 



TYPHOID FEVER IO9 

lymphatic changes are wanting. Splenic enlargement 
was the rule. 

Regarding treatment, there is little to be said, ex- 
cepting that it should be rational and conducted on 
the same lines as in typhoid fever, as rest in bed, liquid 
diet, antipyretic measures and the endeavor to prevent 
the occurrence of complications, the thorough disin- 
fection of all excreta. 



CHAPTER IX 
SMALLPOX 

Definition. — An acute infectious fever characterized 
by an eruption, successively, of papules, vesicles, 
pustules, and crusts. 

Etiology. — The exciting cause of variola is unknown, 
but it is probably a micro-organism of some type. 
All ages are liable to the disease. Negroes and dark- 
skinned people are especially susceptible. 

Smallpox is the most contagious of all diseases. It 
spreads widely, and as a rule attacks all exposed persons 
unless protected by vaccination, previous attack, or 
by natural immunity. 

The contagion exists in the breath, secretions, and in 
the dry scales. The disease may be transmitted from 
dead bodies. 

Symptoms. — Prodromal symptoms are not common. 
The disease usually begins suddenly and with severe 
symptoms. Three or four days of general malaise 
may precede the invasion. 

The symptoms are severe chill, intense headache, 
excruciating pains in the back and limbs, vomiting, 
fever, loss of appetite, and at times convulsions. 

In many cases there is an initial rash which may 
resemble the rash of measles or scarlet fever. 

The fever begins abruptly high and gradually lowers 
until the fourth day or such time as the eruption makes 



SMALLPOX III 

its appearance, when the temperature is normal or 
nearly so. This is a period of great importance as the 
patient who formerly had severe pains, high fever, 
and was generally ill is now free from fever and pain, 
and may consider himself well and thus expose others 
to the disease. This period lasts for only a few days, 
until the eruption assumes the pustular type when the 
temperature goes up to 104 to io5°F. and the patient 
becomes desperately ill. 

The eruption begins from three to five days after 
the invasion. The first manifestation consists of papules 
especially on the forehead, neck, and wrists. The 
papules will roll under the ringer as though they were 
small shot in the skin. This is very characteristic. 
In two or three days the papules are transformed into 
vesicles. These contain clear serum and are multi- 
locular; that is, they are composed of several pockets 
and if pressed with the finger the serum will only par- 
tially escape as some of the pockets are still intact. 
These vesicles become umbilicated, as though the top 
were being drawn in by a string, a small depression 
being formed on the summit of the vesicle. In two 
more days, or on about the eighth day, the vesicles 
become filled with cloudy material of a purulent char- 
acter. The eruption has then reached the pustule 
stage. With the formation of the pustules the tem- 
perature becomes high, io5°F. The pustules begin to 
dry in a few days and the crusts are formed. 

During the course of the disease the pulse becomes 
rapid and feeble and delirium of a severe type may 
develop ; prostration is pronounced. 

Varieties. — Confluent smallpox is very severe. This 
type is characterized by very grave symptoms and 



112 FEVER NURSING 

an eruption similar to that described above, but the 
papules, etc., are very close and thickly set, and ac- 
companied by great swelling of the parts. Superficial 
abscesses are common. The prognosis is grave. 

The hemorrhagic type is the most severe form. 
Hemorrhages occur in the skin around the vesicles 
and into the pustules. Death, as a rule, follows speedily. 

Varioloid is a form of variola modified by vaccina- 
tion. The symptoms are mild. The eruption passes 
rapidly through the different stages. There is no 
secondary fever. 

Complications are laryngitis, edema of the glottis, 
bronchopneumonia, gangrene of the skin, abscesses, 
and pock marks. 

Prognosis. — In the unvaccinated the mortality varies 
from twenty-five to fifty-five per cent., and in the 
vaccinated from five-tenths to two per cent. 

Diagnosis from Chicken-pox. — The invasion is not 
as severe in chicken-pox. The eruption of smallpox 
passes through successive stages, but is, during the 
vesicular stage, entirely composed of vesicles and 
there are no papules nor pustules. The papules in 
chicken-pox do not have the shotty feel. The vesicles 
are not umbilicated or multilocular. In chicken-pox 
the eruption comes in crops, and at the same time 
papules, vesicles, and crusts may be discovered. The 
formation of pustules is not common in chicken-pox. 

Care and Management. — The care and manage- 
ment of a case of smallpox does not differ much from 
that of any other contagious disease. A most important 
part of the care is the prophylaxis, which consists 
chiefly in vaccination. 

Before the discovery of vaccination by Jenner, small- 



SMALLPOX 113 

pox was a most horrible destructive agent to human 
life. It is estimated that in Great Britain alone over 
30,000 deaths were due to this disease every year. 

Vaccination produces in human beings an immunity 
toward smallpox which, though it is not always absolute, 
is very highly protective. The disease itself does not 
entirely protect the patient from future attacks. There 
are many cases on record of a second attack of the 
disease, and even a seventh recurrence is reported. 

There has been much discussion over the protective 
power of vaccination. Some members of the medical 
profession have gone so far as to state that vaccination 
is not only not beneficial, but is harmful. If we could 
protect persons from attacks of other diseases as abso- 
lutely as we protect them from smallpox by means of 
vaccination there would be but little need of physicians 
and nurses. According to Dr. Stark, of England, of 
6000 persons inoculated with smallpox virus after a 
previous vaccination not a single one contracted the 
disease. 

It has been said that vaccination may introduce 
into the patient various diseases as syphilis, tuberculosis, 
erysipelas, etc. It is true that a decade ago or more, 
when humanized vaccines and impure bovine vaccines 
were used, these diseases may have been some few 
times transmitted, but today with improved and pure 
vaccines this is an impossibility. The only source of 
danger is the introduction of pathogenic micro-organisms 
by means of the instruments, dressings or hands of the 
attendants; but this is a possibility in the case of any 
wound and can be entirely eliminated by heeding the 
principles of asepsis and antisepsis. 

All children should be vaccinated during the first 
8 



114 FEVER NURSING 

year of life. Revaccination should be performed at 
the fourteenth year. Physicians and nurses should be 
vaccinated whenever an epidemic of smallpox is im- 
pending, regardless of the length of the interval since 
the previous vaccination. 

Method of Vaccination. — The cuticle is removed by 
means of a few scratches of a sharp, sterile sewing needle. 
The object is not to draw blood, but simply to produce 
an oozing of serum. The vaccine is placed on this 
excoriated area and is slightly "worked in" with the 
needle. 

The most common place for vaccination is at the site 
of insertion of the deltoid muscle in the upper and an- 
terior part of the arm. In right-handed persons use the 
left arm. The female sex, especially those of the upper 
class, prefer to have it on the thigh for obvious reasons. 

Much opposition has been aroused toward vaccination 
because occasional bad after-effects occur. Most of these 
ill results' are due to neglect or faulty technic. Many 
physicians and nurses look upon vaccination as just a 
scratch instead of a surgical procedure as it really is. 

First the field of operation should be made aseptic. 
The author has the site and much surrounding skin 
thoroughly cleansed with hot soapsuds and then rinsed 
with sterile water, and wiped dry with gauze or cotton. 
He does not use an antiseptic for he has found that it 
interferes with or prevents the action of the vaccine. 

After vaccination has been completed the surrounding 
skin, except that within a radius of three-fourths of an 
inch of the site of inoculation, is painted with the tincture 
of iodine and a plain sterile gauze dressing applied. No 
shield is employed. By following this method he has 
never had an ill result. 



SMALLPOX 115 

Signs of Vaccination. — For the first three days nothing 
is noticed as a rule. On the fourth day there may be 
slight redness around the site of vaccination and also 
some itching. A small papule may now be seen. By the 
seventh day this papule or pimple has become a vesicle 
or small blister filled with a clear liquid. A red zone 
forms around this vesicle and may be very extensive. 
Usually about the tenth or twelfth day the liquid oozes 
out of the vesicles and a scab is formed which may 
adhere to the skin for several weeks. After the scab 
or crust falls off a reddened depression or pit remains 
which becomes white in time. 

In some individuals there is no discomfort of any kind 
and they would entirely forget they were vaccinated 
except for the occasional brushing of the affected arm 
against some resisting surface. On the other hand, 
some persons become profoundly ill for a short time, due 
to the constitutional effects of the vaccine. On the third 
or fourth day fever may begin and persist for four or five 
days. The appetite is lost, headache and malaise are 
common, and children may become restless at night. 
Often the axillary or inguinal glands enlarge, depending 
on the site of the vaccination. Suppuration, if it occurs, 
is due to some fault in technic. The arm or thigh where 
vaccination is to take place should be thoroughly cleansed 
with soap and water and some antiseptic solution, and 
finally rinsed with sterile water. The needle and dressing 
should be perfectly sterile. 

Sufficient has been said on the subject of vaccination. 
We will now consider the general management of a case 
of smallpox. 

Isolation is of utmost importance and will probably 
be secured by the Health Board of the community. 



Il6 FEVER NURSING 

The patient should be placed in bed in a well-venti- 
lated room. Light is to be restricted as much as possible. 
The bedclothing should be light. 

Fever should be combated as in other febrile disorders 
(see Chapter IV). 

The diet should be liquid and nutritious, consisting 
principally of milk, broths, gruels, etc. Water should 
be freely given. 

For the intense pain in the back and limbs, which is 
so common in the beginning of the disease, nothing can 
be done except giving anodynes, or the application of 
ice or hot water bags. Plasters and poultices should not 
be used as they increase the irritation of the skin. 

The pulse should be carefully watched so that stimu- 
lation can be instituted as soon as it may be necessary. 

General indications should be met as they arise. 

Pitting. — There is one sign which demands special 
consideration, and that is how to treat the eruption so 
as to leave the least amount of pitting. A great many 
methods have been described to prevent the pitting in 
smallpox. In some instances they do good, whereas in 
other cases pitting results regardless of the greatest 
care taken to prevent it. 

The room should be darkened. It is advised to permit 
only red light to strike the patient. This can be ac- 
complished by having red curtains on the windows, red 
lamp shades and even red wall paper and hangings. 

Probably the best method to prevent pitting is to 
keep the parts constantly moist by covering them with 
cloths moistened with a dilute solution of carbolic acid 
or bichlorid of mercury. A very satisfactory way is to 
anoint the parts with a i to ioo oily solution of car- 
bolic acid, or carbolated vaseline of the same strength. 



SMALLPOX 117 

Touching the base of each ruptured vesicle with a stick 
of nitrate of silver has been advocated. 

Keeping the crusts well soaked with vaseline is of prime 
importance. Whenever carbolic acid is used as a local 
application, careful watch of the urine should be kept, 
in order to detect the signs of poisoning from absorption 
(see Chapter XXVI). 

Warm baths should be given to facilitate the separation 
of the scabs. 



CHAPTER X 
CHICKEN-POX 

Before beginning the description of chicken-pox let 
it be distinctly understood that excepting for part of its 
name it bears absolutely no relation to smallpox, and 
that neither disease protects the individual against the 
other. Vaccination has no influence on chicken-pox. 
Varicella is a name often applied to chicken-pox. 

Chicken-pox may be taken directly from the infected 
person or may be carried by a third person or on infected 
articles. Children are mostly affected, but adults may 
contract the disease. One attack usually protects for 
life and second attacks are very uncommon. The 
incubation period is usually from nine to fifteen days. 

Chicken-pox usually begins quite suddenly with the 
eruption, but at times this may be preceded a few hours 
by some ill feeling. The eruption comes out in " crops, " 
which is very characteristic. The appearance of the 
successive "crops" may be separated by a period of a 
day or two. The first "crop" usually comes on the 
back or abdomen, to be followed later by those on the 
face, scalp and limbs. The eruption has three distinct 
stages : first the appearance of small red spots or papules 
resembling flea or mosquito bites, soon there appears 
on this red spot a small glistening vesicle or water blister 
which in time is followed by the drying process with the 
formation of the crust or scab. As the eruption comes 
in successive crops we thus have at one time all forms of 

n8 



CHICKEN-POX 119 

eruption — red spots, blisters and scabs. The rash is 
thickest on the back, chest and head. In rare instances 
the spots may ulcerate and even gangrenous areas may 
occur. 

Other symptoms are slight fever, coated tongue, rest- 
lessness, disturbed sleep and often extreme itching. 

The scabs in the course of a few days begin to fall off 
and leave behind a slightly reddened area which soon 
becomes natural, color. Pitting after chicken-pox is 
uncommon. As a rule convalescence is rapid and com- 
plications unusual, although ulcerated and gangrenous 
areas may form, and boils, hoarseness, kidney disease and 
ear trouble have occurred. 

The disease is infectious as long as the scabs or ulcera- 
tions persist and usually endures three to four weeks, 
during which time isolation of the patient and quarantine 
should be enforced. 

Care and Management. — Mild cases require but little 
care, excepting rest in bed while the disease is at its 
height and regular feedings of light nutritious food. 
Itching is often very troublesome and requires attention. 
A sponge bath with saleratus water often helps. General 
care as discussed with other diseases will apply here. 



CHAPTER XI 
SCARLET FEVER 

This disease is also known as scarlatina, red fever, 
Scharlach (German), Fievre rouge (French). It is often 
falsely believed that the term scarlatina is applied to 
a light form of scarlet fever, but this is not the case. 

Scarlet fever is not as contagious or infectious as 
measles but is more serious both in course and results. 
Most people sooner or later become afflicted with 
measles but this is not the case with scarlet fever, for 
even many of those exposed to the disease do not con- 
tract it. After the age of fifteen years one is not so liable 
to take scarlatina. One attack protects more securely 
than does measles. The contagion is given off in the 
breath through the mouth and nose, and not so much by 
the scales of skin as formerly supposed. Scarlet fever is 
not contagious as early in the disease as is measles. 
The urine, discharges from nose, mouth, ears and any 
sore or abscesses are highly infectious. Toys with 
which children play while ill with scarlet fever, unless 
very carefully and thoroughly disinfected, may be th^ 
means of spreading the disease months later. 

Symptoms. — After a person has been exposed and in- 
fected it is usually two to six days, generally four days, 
before the first symptoms appear. Unlike the onset of 
measles the beginning of this disease is sudden. The 
three main symptoms of the first day are vomiting, 
headache and sore throat. Other signs are also present, as 



SCARLET FEVER 



121 



tiredness, loss of appetite, coated tongue, restless sleep 
and muscular pains. In very young or weakly children 
convulsions may occur. Usually the first symptom is 
vomiting. The child who has been previously well will, 
without cause, suddenly vomit. This is soon followed 
by more or less severe headache and soreness of the 
throat, especially when swallowing. The fever soon 
begins and may be very high the first day. On the 
second day, the characteristic skin rash may appear. 



DAT! 










































M 


E 


M 


E 


M 


E 


ME 


mIe 


M 


E 


M 


E 


M 


E 


ME 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 




106 
107 

106 
105 
104 

103 




































































103 
107 

106 
105 
104 
103 
































































101 
!00 
99 

93 






























































101 
100 
99 

98 









































































Fig, 12. — Temperature chart of scarlet fever. 



This generally begins, contrary to measles, on the chest 
or body and later appears on the face. The rash varies 
from a pink to bright scarlet. It is not blotchy but 
diffuse and even. It takes on a so-called stippled 
appearance, a multitude of small points located on the 
general bright flush. There may be swelling of the skin. 
When the rash is fully out, if the open hand of the 
attendant be pressed firmly on the patient's back and 
then removed, there remains for some time a white 



122 FEVER NURSING 

imprint of the hand on the patient's skin. Although the 
face may glow there is usually a characteristic pale spot 
on each side of the nose and around the lips. In six or 
seven days the rash has usually disappeared, fading 
away in the order of its invasion. On the second day the 
tongue may take on its peculiar appearance known as the 
strawberry or better the red raspberry tongue. This is 
due to the extreme redness of the tongue together with 
enlargement of the papillae. The throat condition 
advances to great redness and even the formation of a 
membrane on the tonsil. The glands under the lower 
jaw enlarge and become tender. The fever continues 
high for two or three days and then gradually becomes 
lower, usually disappearing about the seventh day. The 
pulse in scarlet fever is usually quite rapid. The urine 
is decreased in amount and may be very dark. Nervous 
symptoms as flightiness, delirium, tremor and sleepless- 
ness may occur. Desquamation or scaling of the skin 
is very prominent in scarlet fever. The more intense 
the rash the greater the scaling. The process may begin 
on the face as early as the third day and then progress 
over the body. The scales from the face are powder-like, 
whereas those from the back may be in great sheets. 
Almost perfect gloves of cuticle may be cast from the 
hands. Desquamation usually takes four weeks. 

Complications and Sequelae. — The complications of 
scarlet fever may be numerous and severe. 

Pseudomembranous pharyngitis is not uncommon. 
There forms on the mucous membrane of the pharynx 
a false membrane, resembling to a degree that found in 
diphtheria. It is due to the streptococcus and is dif- 
ferentiated only by a bacteriologic examination. The 
fauces and tonsils are greatly swollen, as are also the 



SCARLET FEVER 1 23 

glands of the neck. It is in these cases that middle-ear 
disease is very liable, being due to infection through the 
Eustachian tubes. 

Malignant, bloody, or black scarlet fever is a most 
grave condition. In this form there are hemorrhages 
into the skin. The exuded blood becomes dark, and 
from this it derives its popular name. 

Otitis media is common and serious. It is due, as said 
above, to infection through the Eustachian tubes. It is 
a most common cause of deafness in children. The 
mastoid cells may become involved, and later meningitis 
and brain abscesses develop. 

Cervical Adenitis. — The cervical glands enlarge to a 
minor degree in a large percentage of cases. In severe 
cases they may break down and slough, leaving large 
and indolent ulcers. At times an artery may be eroded 
when the slough is cast off, which may result in fatal 
hemorrhage. 

Endocarditis is a not uncommon complication of 
scarlet fever. A patient who has struggled with diffi- 
culty to overcome the ravishes of a prolonged and severe 
attack of the disease may live only to be troubled 
through the remainder of life with a much weakened 
heart. 

Nephritis, although a complication, is really a sequel 
and comes on after the general course of the disease. 
A child who is well advanced in convalescence may be 
exposed to drafts of cold air and develop nephritis. 

It is an old and very proper saying: "In scarlet fever 
look out for the kidneys around the twenty-first day." 
Nephritis of a very severe type may follow a very mild 
attack of scarlet fever. 

The urine, which hitherto has been of a fair amount 



124 FEVER NURSING 

and contained only traces of albumen, now becomes very 
scanty, of a very dark color, and is loaded with albumen. 
It may be smoky or like beef brine, due to the presence of 
blood. The face and lower eyelids may become puffy 
and later a general edema may follow. There are gastric 
disturbances, and vomiting is common. Headache and 
pains in the back may be present. The disease may 
only be mild or may progress and signs of uremia 
develop. 

The number of cases of nephritis following scarlet 
fever may be greatly lessened by careful nursing. Do 
not allow the child to leave its bed until directed by the 
attending physician. The child may have had a most 
mild attack and the parents may think it unnecessary to 
keep the child in bed, or the child may be restless and 
desirous of getting up in a chair, but be careful, for it is 
in these cases that the most malignant form of kidney 
disease may occur. Be careful about exposing the child 
to drafts. 

Other important complications which may occur are 
pleurisy, pneumonia, chorea, rheumatism, and peri- 
carditis. 

Before discussing the treatment and care of the patient 
I wish to call attention again to the seven cardinal signs. 
During the first day we have: sudden causeless vomit- 
ing, severe headache, sore throat, high fever, convulsions 
in the very young. 

Second day: diffuse scarlet punctate rash, strawberry 
tongue. 

Care and Management. — How often do we hear the 
expression, "I have had a discharge from the ear ever 
since my illness with scarlet fever;" or "my kidneys have 
been weak," or "I am unable to work or exert myself as 



SCARLET FEVER 12 5 

other people do because my heart was affected by 
scarlatina years ago." These are very common ex- 
periences, and are very sad ones because they could have 
been avoided in many cases if proper care and nursing 
were instituted during the attack of scarlet fever. 

As in all contagious diseases isolation is absolutely 
necessary. The patient and her immediate attendants 
should be placed in a suite of rooms farthermost from 
the general rooms of the rest of the household. Nobody 
except the medical attendants should be allowed admis- 
sion to the sickrooms. All the unnecessary furniture, 
hangings, and picture frames should be removed from 
the room. A separate set of eating utensils should be 
used. If there are any public-library or school books 
in the house, they should not be returned until after 
disinfection. 

The patient should be placed in bed and covered 
with light bedclothing. Ventilate the rooms well. Do 
not be afraid of air. Other children of the family 
should not be allowed to go to school or mingle with 
outside children. It is better not to remove them to 
another house as it is probably too late to be of good. 
They should not come in contact with attendants of the 
patient or any clothing from the sickroom. A daily 
walk in the open air is a necessity. Keep careful watch 
of them so in case they have become infected treatment 
may at once be instituted. Arrangements must be 
made to keep the patient in bed at least three weeks. 

Diet. — As in all febrile disturbances the appetite is 
impaired and the digestive functions are below par; 
therefore, it is necessary to provide food which is easily 
digested and does not require much work on the part of 
the digestive organs. The kidneys are very easily dis- 



126 FEVER NURSING 

turbed in this disease, so that food which is irritating to 
the kidneys, or throws extra labor upon them, should be 
eliminated from the diet. We know that meats, espe- 
cially the red meats, do cause increased renal effort. 

The requirements are that the food should be bland, 
liquid, or at least very soft, and highly nutritious. Milk 
will meet all these requirements and should form the 
basis of the diet. It may be diluted with water, lime- 
water, barley water, or a carbonated water. 

Water should be freely given. Lemonade is allowable. 
A very pleasant beverage is prepared by adding a tea- 
spoonful of cream of tartar to a quart of boiling water 5 
the juice of a lemon, and sugar to taste. Serve cool. 

A daily tepid or cool bath is of service and is refresh- 
ing. Should the temperature range high the bath may 
be made cooler and repeated several times during the 
day. 

The mouth, nose, and throat should receive daily 
attention. They may be sprayed, swabbed, or douched 
with some mild antiseptic as a two per cent, solution of 
boric acid, a i to 16 solution of hydrogen peroxid, a i 
to 2000 solution of potassium permanganate, or one of 
the many alkaline antiseptics prepared by the reputable 
drug houses of this country. 

For pain in the throat nothing is more serviceable 
than the external application to the neck of an ice-bag. 
If objections are made to cold, then hot water may be 
applied. In older children the sucking of small pieces 
of ice is very agreeable and beneficial. 

Headache is best relieved by the application of an 
ice-bag, or rubbing the head with some evaporating 
solution, as alcohol or a two per cent, solution of menthol 
in alcohol. 



SCARLET FEVER 1 27 

Sleeplessness and delirium are best combated by cool 
baths and an ice-bag to the head. 

Ear complications are not infrequent and are very 
serious. If the patient complain of earache, or a slight 
discharge is seen coming from the external auditory 
meatus, call the physician's attention to it at once. 

For earache nothing is better than the application of 
heat. This is best accomplished by rilling a common 
rubber fountain bag with water at a temperature of 
105 F. Raising the bag just above the level of the 
ear, allow the warm water very gently to enter the 
external auditory canal. 

When a discharge is present the ear may require 
douching. This is done in the same way, except with 
some antiseptic solution instead of water. A one per 
cent, solution of boric acid or a two per cent, solution 
of carbolic acid may be used. 

Kidney Complications.— -The main question is how 
to prevent the renal complications. In some instances 
they cannot be prevented, no matter what is done. If 
the following suggestions are heeded the danger will 
be reduced to a minimum: 

Keep the patient in bed for a sufficient length of time, 
at least three weeks. 

Prevent the patient from exposure to cold. 

Give water freely. 

Be careful in regard to diet. Permit no meat, broths 
or gruels. 

When nephritis makes its appearance, the bowels 
must be kept freely open with saline laxatives. The 
diet must be entirely milk. Water should be given 
in abundance. The object is to relieve the kidneys of 
part of their work. Sweating is to be encouraged by hot 



128 FEVER NURSING 

packs and baths. Hot normal saline enemata are very 
useful. Hypodermoclysis of normal saline solution may 
be given in the more severe cases. 

Heart Weakness. — The toxines of scarlet fever seem 
to have a peculiar affinity for the heart structures, and 
may result seriously. If the pulse become rapid, irregu- 
lar, or altered in rhythm, the medical attendant's notice 
should be called to it. Prevent as much physical exertion 
on the part of the patient as possible. 

When desquamation begins the body should be 
anointed with some oily preparation, as olive oil, lard oil, 
vaseline, lanolin, or glycerite of starch. This will render 
desquamation more rapid and will prevent the diffusion 
of the scales. Before anointing the skin with oil or 
vaseline, it should be washed with warm soapsuds. 
All pieces of scaly skin should be immediately burned 
when removed. 

Quarantine. — This is a much debated subject. No 
length of time can be given, but it can generally be said 
that quarantine must be enforced until desquamation 
or scaling has completely ceased. If scaling has ended 
and there is still a discharge from the nose, throat, 
or ear, danger is still present. 

After the patient has recovered it is necessary to pre- 
pare the room for occupancy by the household. This 
is best accomplished by fumigation or disinfection. Fore- 
most of all disinfectants at the present time isformaldehyd 
gas. Leave all the patient's and nurse's clothing in the 
room. Loosen the bedclothing and hang it about the 
room on chairs. Close all the windows and calk their 
loose joints and also the crevices about all doors. Open 
the drawers of all furniture in the room. Stand books 
on their ends and separate the pages. With a whisk 



SCARLET FEVER 120. 

broom immersed in water, or a small sprinkler, dampen 
slightly the carpets and clothing in the room. Every- 
thing is now ready for the disinfection. 

Formaldehyd gas is set free in three different ways: 
By heating wood alcohol; by heating the solid formalde- 
hyd; and by heating formalin, which is a forty per cent, 
solution of formaldehyd. Apparatus for generating the 
gas may be purchased for a moderate sum, or an ordinary 
alcohol lamp placed under a tin vessel containing for- 
maldehyd or formalin may be used. Henry V. Walker, 
of Brooklyn, has devised a very simple and effective 
method of generating the gas, devoid of all danger. 

To six ounces of formalin add two ounces of com- 
mercial sulphuric acid, and mix this with one pound of 
unslaked lime. This amount is sufficient for 1000 
cubic feet capacity. If the room be larger than this, 
use larger quantities of the chemicals. This method 
has the advantage of cheapness, freedom from fire, and 
does not require any special apparatus. It is very rapid 
and efficient. 

After placing the mixture in the room to be fumi- 
gated, close the door tightly and allow the room to 
remain closed for twenty-four hours; then open all 
the windows to free it from odor. The room is now 
ready for occupancy. 

Precautions. — -Certain precautions are necessary to 
prevent the nurse from contracting the disease, espe- 
cially if she has never had it. The nurse should be out 
of doors as much as possible when off duty. Keep the 
sickroom thoroughly ventilated; a draft is of great 
harm to the patient, but ventilation is not only not 
harmful, but necessarv. 



130 FEVER NURSING 

The nurse should change her clothing frequently, and 
also the bedclothing. 

Keep the mouth, nose, and throat clean by means of 
gargle and sprays. 

Keep all the exposed parts of the body in as clean 
a condition as possible. 

All secretions and excretions of the patient should be 
carefully collected and thoroughly disinfected. 

A separate set of eating utensils should be used for 
the patient. 



CHAPTER XII 

MEASLES 

Measles is the most contagious and frequent of the 
common diseases of childhood. There is no disease which 
is more widely disseminated, once it enters a community, 
than measles. All people, sexes, ages and classes are 
about equally susceptible to this ailment. More cases 
occur in childhood for the reason that most adults are 
immune because of earlier attack- 
Measles is contagious or "catching" from the earliest 
symptom, three or four days before the rash begins, until 
the eruption fades away. It is probably more contagious 
in the earliest stages. After exposure and infection it is 
usually ten days before the first signs appear and four 
more days, or fourteen in all, before the rash begins. This 
is not a hard and fast rule, for it may be four days sooner 
or later than this. 

Measles is also known as rubella, morbilli, and masern 
(German), Rougeole (French). 

One attack does not necessarily confer immunity; 
instances of two, three and four attacks are not uncom- 
mon. The infection is given off from the mouth and 
nose in the breath. 

Symptoms. — Measles begins as a feverish "cold in 
the head." The nose discharges, the eyes are watery 
and irritated, there is some fever, a feeling of tiredness and 
general languor, sleep is wanting or restless and there is 

131 



132 



FEVER NURSING 



a harsh dry cough. In fact before the eruption appears, 
if there is no history of an epidemic or infection, it is 
difficult to say whether the patient is ailing with measles, 
whooping-cough or a simple cold or probable bronchitis. 
The fever in this early stage may become very high and 
in weakly children and young infants delirium or even 
convulsions may happen. The cough is very harsh, 




Fig. 13. — Temperature chart of measles. 



dry and unproductive. Very little or no phlegm may be 
expectorated. Soreness and rawness in the chest and 
throat may result from the harsh cough. In fact, in 
many cases the cough is the most distressing of the 
early symptoms. On the second or third day there often 
appears on the inside of the cheeks, opposite the grind- 
ing teeth, small white-blue spots surrounded by a pink 
or red area, which are quite certain in making sure the 
disease is measles. These are called Koplik spots after 
the physician who first described them. The membrane 
of the throat becomes red and glossy and in the roof of 



MEASLES 133 

the mouth, just in front of the uvula, may be seen little 
raised specks or elevations. These usually occur before 
the skin eruption. 

The skin rash usually appears four days after the first 
symptoms are noticed. The fever which was high in 
the early stage may disappear before the rash comes, but 
usually goes high again as the skin breaks out in full 
eruption. The eruption, consisting of pale pink pimples 
or elevations, is generally first seen on the forehead 
just below the hair line or back of the ears and then 
spreads downward over the face, chest, arms, abdomen 
and lower extremities. The eruption becomes brighter 
and may be arranged in groups, taking on a crescentic 
outline. The rash may be very scant or very profuse. 
It is hardly ever so abundant but what little islands of 
natural skin may be seen scattered about, and in this 
way differs from scarlet fever. The eruptions on the 
face may begin to fade away before the legs are covered 
with rash. The face at the height of eruption is swollen 
and actually looks " boiled, " which is very characteristic. 
As time passes the eruption may take on a purplish hue. 
During the eruptive stage all the symptoms may be 
exaggerated. The cough is very discomforting, hoarse- 
ness of great degree may occur, diarrhea is not uncommon, 
the eyes are sore and very susceptible to light and in 
general the patients feel very "mean" for a day or two. 
After three to six days the rash disappears and may be 
followed by a fine floury scaling. All the symptoms 
gradually decrease in severity and cease. 

Measles may occur in a form so light that it is hardly 
suspected or may occur in a very severe form accom- 
panied by very high fever, delirium, dry cracked tongue, 
weak rapid pulse, coma and intense nervous symptoms. 



134 FEVER NURSING 

Complications in well cared for cases are not frequent 
but in those not properly attended many disorders may 
arise, principally bronchopneumonia, middle-ear ab- 
scesses, severe eye disease, heart affections and mouth 
trouble. Tuberculosis is not a rare follower of measles. 

Care and Management. — In measles as in all diseases 
of childhood accompanied by fever the patient should 
be placed in bed. Small infants should not be carried 
or held in the lap, but they also should be comfortably 
put in a crib or bed. The complaint that young children 
will not remain in bed without crying and fretting is 
without foundation if they are properly managed. The 
patient should not be smothered with bedclothing but 
lightly covered with a sheet and thin quilt or blanket. 
The temperature of the room should not exceed 65 F. 
The room should not be dark nor on the other hand 
extremely bright, but simply shaded. A very dark 
room is depressing to both patient and attendant and 
may become one of the factors that urges on complica- 
tions. The item of prime importance is the ventilation 
of the sickroom. Give the child plenty of fresh air for 
in so doing you make him more comfortable, you may 
shorten the course of the disease and above all may pre- 
vent such serious complications as bronchitis, laryngitis 
and bronchopneumonia. As mentioned in a previous 
part of this book, all extraneous furniture and fixings 
had better be removed from the room. The diet of the 
patient is a next consideration. If the patient is a 
nursing child the strength of the milk should be reduced 
one-third to one-half. Older children should be placed 
mainly on milk foods. A feeding should be given every 
two hours during the day. Milk should first be diluted 
with water, barley water or vichy. Cereal gruels may 



MEASLES 135 

alternate the milk feedings. Albumen water, toast, 
soft eggs, clam or oyster broths, with milk and custards, 
may be substituted occasionally. Plenty of water to 
drink is important. Orangeade and lemonade are agree- 
able but should not be given near a milk feeding. As 
the fever leaves and convalescence advances other articles 
of food may be given. It is well to omit from the diet 
for some time meats or their products, as soups and 
broths. A warm sponge bath may be given morning 
and night with very beneficial results. The warm night 
bath encourages sleep and restfulness. If the fever 
mounts high, baths, even cool, should be frequently 
given. The bowels should move once daily and if there 
is no tendency toward this a suppository or enema should 
be employed. The mouth should be kept in a cleanly 
condition by the frequent use of a mouth wash or gargle. 
Employ one of the solutions mentioned in the Addenda 
or as your physician may direct. 

For the treatment of the various symptoms you must 
depend on the attending physician; nevertheless there 
are some simple procedures which, combined with your 
physician's services and at his direction, will tend to 
make the patient more comfortable. 

For the distressing cough the application of hot fomen- 
tations or packs to the upper and front part of the chest 
and around the neck will often be found very helpful. 
Also you will rind of extreme service for the harsh cough 
the saturation of the air with steam, which may be best 
done by means of a bronchitis tent, for troublesome 
hoarseness, the use of an ice-bag to the front of the throat 
in older children or hot packs for the younger. For 
eye irritation the use of an eye drop four or five times a 
day is useful. A four per cent, solution of boracic acid 



136 FEVER NURSING 

may be employed. For restlessness, very material bene- 
fit will result from a warm sponge bath. For diarrhea 
in addition to medicine prescribed by the physician, 
hot scalded milk thickened with arrowroot is good. For 
itching, which may be very annoying, a warm saleratus 
sponge will often relieve. 

Quarantine. — 'When quarantine is about to be raised, 
before removing the child from the sickroom he should 
have a full hot soap bath and an entire set of fresh 
clothing put on, leaving the old clothing in the room for 



CHAPTER XIII 
GERMAN MEASLES 

This disease, although hardly ever requiring the care 
of a trained nurse, is discussed because of the liability 
of its confusion with measles and scarlet fever. 

Synonyms. — -Rubella, hybrid scarlet fever, French 
measles, epidemic roseola, and rotheln. 

Etiology. — -The exciting cause of rubella is un- 
known. It is contagious and the epidemics may be 
widespread and travel rapidly. In small towns it has 
been known to have entered every household. 

It was supposed to be akin to measles and scarlet 
fever, but a previous attack of either of these diseases 
will not protect the individual from rubella; neither 
will an attack of German measles protect from invasion 
of measles or scarlet fever. 

Symptoms. — -The course of German measles can 
readily be divided into four parts, namely, incubation, 
invasion, eruption, desquamation. 

The incubation period varies from ten to sixteen 
days. 

The invasion is, as a rule, gradual and the symptoms 
are mild, although the patient may be very ill. 

The disease usually begins with malaise, headache, 
pharyngitis, and rarely with coryza and conjunctival 
disorders. There may be nausea, vomiting, pains in 
the back and legs. Enlargement of the glands behind 
and just below the ears is early, prominent and very 

137 



138 FEVER NURSING 

characteristic and may even occur before the rash ap- 
pears. The throat may be reddened and sore to a 
greater degree than in measles. The fever for a short 
time may reach a considerable height. There may be 
an irritating cough. In many cases all the symptoms 
are so light that the child hardly appears ill. 

The eruption usually begins within twenty-four or 
forty-eight hours after the infection. It makes its 
appearance first on the face and then spreads rapidly 
over the whole body. This may be complete in twenty- 
four hours and is very characteristic. The rash is 
more pronounced on the flexor surfaces of the limbs. 
The eruption, which may resemble that of scarlet fever 
or measles, lasts two or three days and then fades in 
the order of its appearance. 

The scarlatinal form is often mistaken for scarlet 
fever. The rash is of a bright red, but is very uniform 
and smooth, and stippling, so prominent in scarlet 
fever, is absent. The sore throat is of a mild type, as 
is also the fever. 

The measly form is often mistaken for measles. The 
rash is of a bright red color but the regular crescentic 
arrangement, so characteristic of measles, is lacking. 
Desquamation is slight and branny. 

Diagnosis. — 'The diagnosis of rubella is made from 
its mild symptoms, slight fever, the enlargement of 
the cervical glands, and the rapid appearance and dis- 
appearance of the rash. 

Prognosis is good. At times, however, the dis- 
ease takes a very severe course. 

Complications of rubella are few. The enlarged 
glands may soften and become abscesses. Pneumonia, 
nephritis, and intestinal disorders may occur. 



GERMAN MEASLES 139 

Management. — -Rest in bed and quietness for at 
least one week are essential. Confinement to the bed 
may be difficult to enforce on account of the mildness 
of the disease. 

Cold or hot applications, preferably the former, to 
the neck are useful. The patient should be quaran- 
tined for at least three weeks. 



CHAPTER XIV 
MUMPS 

Mumps or epidemic parotitis is an infectious disease 
usually occurring in epidemics. The seat of the disease 
is the parotid gland which is one of the organs that 
produce saliva. The parotid glands are located on the 
side of the face just below and in front of the ear. 
The submaxillary glands, which are located beneath the 
lower jaw on the sides, may also become involved. 

The incubation period, or the time that elapses 
between the time of infection and the appearance of 
the first symptom, may vary from fourteen to twenty- 
one days or even more. The mode of infection is 
rather directly from the infected person than through 
a third individual. One attack usually confers complete 
immunity. The most common age is six to sixteen 
years and adults are rarely affected, but if so the 
disease is generally more severe. 

Symptoms. — The disease begins with several days 
of malaise, headache, feverishness, chilliness, sweating, 
ringing in the ears, neuralgic pains, loss of appetite, 
and there may be bleeding from the nose. The swell- 
ing begins below and in front of the ear, and gradually 
extends upward and backward, so that the tumor be- 
comes shaped like a stocking. This tumor is tender 
and accompanied by more or less pain. There is a 
very tender area behind the angle of the jaw near the 
tip of the mastoid process of the temporal bone. 

140 



MUMPS 14I 

It is difficult and painful to open the mouth widely. 
The saliva is usually scant and the mouth dry. An 
acid introduced into the mouth causes great pain and 
discomfort, due to its stimulating the flow of the saliva. 
Swallowing is painful. The disease often affects both 
sides and may involve the testicles or ovaries. 

The course of the disease is from three to six days, 
but may be extended and complicated. 

Complications. — This disease, although generally of 
a mild character, may be seriously and gravely com- 
plicated. 

Cerebral disorders, delirium, and coma may occur. 
Suppuration of the gland, orchitis, mastitis, ovaritis, 
deafness, pneumonia, endocarditis, and pericarditis are 
among the other complications. 

Management. — The patient should be kept in bed 
during the acute course of the disease. Liquid diet 
is about all the patient will be able to take. Mouth 
washes and gargles are useful. 

For extreme pain and tenderness hot applications are 
very good. If the child will permit, there is nothing 
more soothing than the application of an ice-bag to the 
swelling. A hot lotion of lead and opium, locally 
applied, is useful. 

For orchitis, support and protection are sufficient. 

Tepid or cool sponging if the fever be troublesome. 



CHAPTER XV 
WHOOPING-COUGH 

Whooping-cough, also known as pertussis, chin cough, 
Keuchhusten (German), and Coqueluche (French), is 
a very infectious disease often occurring in widespread 
epidemics. Once it enters a community it may attack 
nearly all the non-protected inhabitants. It is very 
contagious and only a short exposure is necessary to 
become infected with this disease. The affected person 
may begin to affect others long before the whoop makes 
its appearance. It is doubtful whether this disease 
may be carried in the clothing. A direct contact with 
the patient's breath is probably necessary. 

After exposure the time to elapse before the disease 
makes its appearance varies, but it is found that ten to 
fourteen days is the likely period of incubation. 

Symptoms. — The course of whooping-cough may 
quite handily be divided into three stages, each of about 
equal length. Of course this is not always the case but 
in the long run of patients it is quite satisfactory. 
These three stages each average a length of about two 
weeks and are the stage of catarrhal symptoms, the 
stage of whooping, and the stage of decline. The first 
symptoms are those of a catarrhal cold: there is slight 
fever, tiredness, restless sleep, lack of appetite, also 
at times symptoms of a "cold in the head' 1 as discharge 
from the nose, watery and reddened eyes and sneezing 
are present. The most characteristic symptom of this 

142 



WHOOPING-COUGH 1 43 

early stage is the cough and it is a very annoying and 
distressing affair. It is unproductive, that is, very little 
is raised in proportion to the cough; it is dry and irrita- 
ting and is usually worse at night, thus interrupting the 
patient's rest. The cough may come on in paroxysms, 
that is, there are "fits" of coughing followed by periods 
free from cough. During this stage the whoop is usually 
absent and unless there are other cases in the vicinity 
the character of the disease up to this time may remain 
covered. 

The stage of whoop follows immediately upon the 
former stage and is characterized by the peculiar cough; 
this cough occurs in paroxysms or "fits" and consists of 
a series or succession of short expiratory efforts until the 
lungs become practically exhausted of air, when the 
spasm is relieved and air rushes in with a shrill sound or 
whoop. The paroxysms may be so severe that the child's 
face becomes purple and it seems that another breath 
is impossible, when the "spell" begins to abate by air 
entering the lungs. During the severe whoops the child 
may be under a great nervous stress and dread and runs to 
some older person for aid. Vomiting very often follows 
the attack and if persistent is serious because of its 
interference with the child's nutrition. If the attacks 
are frequent and severe the child is placed under a very 
great physical strain and quickly becomes exhausted. 
At times small blood-vessels may rupture and the skin 
have the appearance of bruise spots. Ruptures have 
been produced. 

The stage of decline is simply a decrease and wearing 
away of the symptoms of former days, especially the 
whoop which becomes less both in frequency and severity. 
The child begins to improve in various ways and food 



144 FEVER NURSING 

is better retained. The stage lasting about two weeks, 
makes the average length of the disease about six weeks. 

Complications.— -Bronchopneumonia is very frequent. 
Pleurisy, emphysema, pulmonary collapse, persistent 
vomiting, hemorrhages from the nose and lungs, menin- 
geal hemorrhages, convulsions, and intestinal catarrh 
are among the complications of pertussis. 

Sequelae. — -Pulmonary tuberculosis often follows an 
attack of whooping-cough, and care to prevent it must 
be exercised. 

Care and Management.— Whooping-cough is a disease 
of some seriousness and is made doubly so by the fact 
that it is often complicated by bronchopneumonia 
and makes the patient particularly vulnerable to 
pulmonary tuberculosis. 

The treatment of the disease with medicines is espe- 
cially unsatisfactory. A great many drugs have been 
advocated. Although the nurse has no power to pre- 
scribe remedies, nevertheless a partial list of the drugs 
are appended so as to emphasize the uncertainty of 
drug treatment. 

They are belladonna, antipyrin, acetanilid, phenacetin, 
quinine, bromoform, bromids, chloral, opium, cannabis 
indica, amyl nitrite, cocaine, chloroform, resorcin, 
lobelia, croton chloral, ichthyol, salicylates, etc., etc. 

The patient should be kept in a large, airy, well- 
ventilated room. Plenty of fresh air is absolutely neces- 
sary. The breathing and rebreathing of the same 
infected air prolongs the course of the disease and 
increases the number of paroxysms. In summer have 
all the windows open. In whooping-cough the lungs 
and the mucous membrane of the respiratory tract are 
very sensitive to cold, and for this reason great care 



WHOOPING-COUGH 145 

must be exercised that the patient be not exposed to 
draughts. 

The diet is to be liquid and highly nutritious. Dur- 
ing the paroxysmal stage vomiting may occur after 
each fit of whooping. In order to prevent this and to 
maintain the nourishment of the child it is best to give 
a very small amount of milk after each paroxysm, 
instead of larger quantities at longer intervals. 

If the disease be seen in the very early stages, it may 
be abated, shortened, or lessened in severity by spray- 
ing the mouth, nose, and pharynx with some germicidal 
solution. Peroxid of hydrogen gives excellent results 
when used for this purpose. Prepare a solution of 
equal parts of glycerine and peroxid of hydrogen and 
use this, well diluted, as a spray. 

If the cough be dry and troublesome, it may be 
greatly relieved by saturating the air of the room with 
steam or by employing a bronchitis tent. 

A bronchitis tent may be improvised as follows: If 
the bed posts do not reach a height of three feet above 
the patient, then fasten to each corner of the bed a 
stick — a broomstick will do — so that the top of each 
upright stick is three feet above the patient. Place a 
sheet over these sticks so as to form a canopy or awn- 
ing above the child, and so that three sides of the bed 
are covered, thus forming a tent with a covered top 
and three sides, one side being open. Under this tent 
conduct by means of tin pipe or hose steam from a 
nearby kettle of boiling water. 

Belladonna is one of the most frequently used drugs 
in the treatment of whooping-cough, and probably ex- 
erts the greatest benefits. An excellent way of main- 
taining constantly the action of this drug is by placing 
10 



I46 FEVER NURSING 

a freshly made belladonna plaster on the back of the 
patient, preferably between the shoulder blades. The 
plaster may be renewed every five or seven days. 

During the very severe paroxysms, a few whiffs of 
chloroform are very useful. Pour a few drops of 
chloroform on the palm of the hand and allow the 
patient to inhale the vapors from your inverted hand 
as it is held near the patient's nose. 

A mustard paste to the front of the chest is useful 
in excessive and harsh coughing. 

The use of the Kilmer belt has been followed by 
good results in the author's practice. Although these 
belts are on sale, one may be improvised at home. 
Place about the child's body a band of white cotton 
flannel or woolen flannel, reaching from just below the 
armpits to the bottom of the abdomen. This should 
be applied firmly, smoothly and tightly. By this 
scheme the number and severity of whooping par- 
oxysms may be reduced, and, as a rule, comfort is 
great and grateful. 

Whooping-cough is contagious; therefore, isolation 
of the patient is as necessary as in other communicable 
diseases. 



CHAPTER XVI 
INFLUENZA 

Synonyms. — La grippe, epidemic catarrh, catarrhal 
fever. 

Definition. — An acute, infectious fever, occurring 
epidemically or pandemically, and characterized by se- 
vere general pains, great prostration, and involvement 
of the mucous membrane of the respiratory or alimen- 
tary systems and more or less pronounced nervous 
phenomena. 

Etiology. — The exciting cause is the bacillus of 
Pfeifler. At times the disease appears to be conta- 
gious; at any rate it is very infectious. The bacillus 
is found in the secretions of the nose and bronchi. 

The disease spreads with great rapidity and affects 
more people at one time than any other disease. 

In large cities it may reappear every two or three 
years. 

Infants are less susceptible than older children and 
adults, and when they do contract it they have a less 
severe form and the sequelae are less frequent. 

Symptoms. — The incubation period is from one 
to four days. The onset is abrupt, beginning with 
sensation of chilliness or even a severe chill, malaise, 
loss of appetite, great prostration, moderate fever, and 
severe pains in the head, back, and limbs. Herpes is 
common . 

There are four principal forms of influenza: The 
i47 



I48 FEVER NURSING 

respiratory form, characterized by coryza, sneezing, 
watery discharges from the nose, injection of the con- 
junctivae, hoarseness, cough and raising of thick, puru- 
lent masses of sputum. There are also symptoms of 
severe bronchitis, the pulse becomes rapid and prostra- 
tion is out of proportion to the fever and other symp- 
toms. Laryngitis of a severe type may occur, accom- 
panied by a metallic cough, hoarseness, or even a loss 
of voice. 

The alimentary form is characterized by nausea and 
vomiting, diarrhea, abdominal pains, rise of tempera- 
ture, and in some cases jaundice. The symptoms of 
the respiratory form may also be present. 

The nervous form is often devoid of any catarrhal 
symptoms. The pains in the head, back, and limbs are 
extremely severe; insomnia is very troublesome, the 
prostration is great, chills are common, and meningitis 
and hemiplegia may occur. 

The typhoid form is characterized by a continuous 
irregular fever. The temperature may become very 
high, the pulse be very rapid, and delirium and other 
nervous phenomena are not uncommon. This form 
simulates typhoid fever to some degree. 

Course. — In mild cases the pains are soon relieved; 
the temperature becomes normal in four or five days 
and convalescence ensues. In more severe cases the 
course of the disease is prolonged and the prostration 
continues until convalescence is far advanced. The 
cough may persist for weeks. 

Sequelae. — Weakness, tiredness, and debility are fre- 
quent sequela?. Palpitation of the heart, tachycardia 
or bradycardia are frequent results. Commonly fol- 
lowing influenza are severe nervous complications of a 



INFLUENZA 1 49 

functional type, such as neurasthenia, hypochondria, 
melancholia, and suicidal tendency. 

Influenza often excites into an active form many 
latent diseases. If there be a lurking area of tuber- 
culosis, it will undoubtedly become active. 

The susceptibility for all diseases is increased and the 
resistance of the individual lessened. 

Complications. — Pneumonia of the regular type may 
occur, or that form known as the grippe pneumonia, due 
to the influenza bacillus; the import is grave. Pleurisy, 
neuritis, nephritis, meningitis, insanity, cardiac lesions, 
and phlebitis occur. 

Prognosis. — Influenza is slow in convalescing. It 
is a very grave disease in persons affected with tuber- 
culosis, nephritis chronica, asthma, and cardiac disease. 
In elderly individuals the prognosis is also grave. In 
the young it is not serious. In many cases the disease 
itself is entirely eradicated, but nervous disorders of more 
or less permanency remain. 

Care and Management. — Isolation is necessary and 
should be maintained. The attacks may be light in 
severity, but every person at all acquainted with medicine 
has frequently seen this disease transmitted to every 
member of a household because isolation was neglected. 

Rest in bed is imperative. The room should be large 
and well ventilated. The diet should be liquid while 
fever persists, after which semi-liquid articles may be 
added to the dietary. 

All excretions, especially those of the upper respiratory 
passages, should be collected and destroyed. The cloths 
used, as handkerchiefs, are to be burned. 

If the temperature becomes excessive, then cool or 
cold sponges and baths should be employed. 



150 FEVER NURSING 

For the headache nothing is so useful and agreeable 
as the application of an ice-bag to the head. 

Sleeplessness may be overcome by tepid sponges, a 
hot foot bath or an ice-bag to the head. A hot drink 
will often induce sleep. 

The nose, mouth, and throat should be kept clean 
by means of sprays, douches, gargles of mild antiseptic 
solutions, as a two per cent, solution of boric acid, a 
1 to 1000 potassium permanganate solution, of hydrogen 
peroxid, 1 to 8. 

For irritating bronchitis steam inhalations or the use 
of a bronchitis tent will be found an excellent means of 
relief. 

For the severe pains in the chest and back, the mus- 
tard paste is a most excellent agent. Turpentine and 
lard rubbed over the parts is good. A liniment com- 
posed of equal parts of alcohol, soap liniment, and weak 
ammonia water is quite efficient. 

Cardiac depression sometimes occurs very suddenly 
and immediate action is necessary on the part of the 
nurse. For this purpose use strychnine, gr. one-thirtieth 
hypodermically, and aromatic spirits of ammonia either 
alone or combined with the compound spirits of ether, 
given in dram doses. The last two should be well 
diluted with cold water before administering. 

The convalescence from influenza is very slow. The 
patient rallies very gradually from the extreme weakness. 
The general functions of the body are at a low ebb. 
After the fever has disappeared the temperature goes 
toward the other extreme and a subnormal condition is 
very frequent. The heart in many cases becomes quite 
slow. This low temperature makes the patient very 
susceptible to draughts and climatic disturbances. It is 



INFLUENZA 151 

very important that the patient does not leave her bed 
too soon, and when permitted to do so, in the beginning 
it should be for short periods. A part of the day should 
be spent in bed until convalescence is well advanced. 

Massage is very useful in toning and repairing the 
wasted muscles. 

The diet should now be varied and highly nutritious. 
Milk and eggs should be frequently taken. 

When the patient has become fairly strong, but not 
until then, a visit to the mountains or seashore or a 
short sea trip will be very beneficial. 



CHAPTER XVII 
EPIDEMIC CEREBROSPINAL MENINGITIS 

Etiology. — The cause of epidemic cerebrospinal menin- 
gitis is the diplococcus intracellularis. Young children 
are very susceptible to the disease. It also breaks out 
in crowded places as in barracks, prisons, etc. Cerebro- 
spinal meningitis is a very serious and often fatal dis- 
ease. The membranes covering the brain and spinal 
cord are inflamed. The disease occurs most frequently 
under the age of nine or ten years. The germ is found 
in the secretions and excretions of the nose, throat and 
ears, and by this means the disease is spread. 

Symptoms. — The onset of the disease as a rule is 
sudden. A chill as severe as the initial chill of pneu- 
monia may usher in the disease, followed by severe 
headache, vomiting, convulsions in the very young, 
pains in the back, loss of appetite, great irritability, 
somnolence. The temperature rises to io2°F. or there- 
abouts, the pulse is at first full and strong and may 
become very slow, the neck becomes stiff, strabismus 
develops, and photophobia or dread of light is not un- 
common. In severe cases there are, in addition, spasms 
of a tonic or clonic character, opisthotonos, delirium, 
stupor, coma, and Cheyne-Stokes respiration. Herpes 
labialis is of common occurrence. 

Petechia? and purpuric spots may develop in the skin, 
and it is from this that the disease acquired the name of 
spotted fever. 

152 



EPIDEMIC CEREBROSPINAL MENINGITIS 1 53 

Course. — There are three types of this disease. 

A mild form in which the symptoms rapidly occur and 
in three or four days disappear and a rapid convalescence 
follows. 

A simple acute form, characterized by a more or less 
irregular course of six to fifteen days' duration. The 
symptoms may be severe but complications are slight or 
absent. 

A fulminating form which begins abruptly and with 
very severe symptoms. The purpuric rash is common 
and death releases the patient in a very short time. 

Complications. — Pneumonia is not an uncommon 
accompaniment of cerebrospinal meningitis. Pleurisy 
also occurs. Pericarditis, arthritis, parotitis, and peri- 
tonitis may develop. Neuritis, paralysis, blindness, 
deafness follow complications involving nervous struc- 
tures. Hydrocephalus, otitis media and mastoiditis, 
chronic headache, and mental feebleness may result. 

Prognosis. — The mortality varies from twenty to 
seventy-five per cent. Cases of the fulminating type 
seldom recover. 

Diagnostic Points. — Suddenness of onset, severe 
headache, projectile vomiting, bulging fontanelles, stiff 
neck, and apathy. 

Kernig's sign is of diagnostic importance. To elicit 
this sign, place the patient on his back and flex the 
thigh on the body; now, if meningitis be present, it 
will be impossible to extend the leg on the thigh because 
of the muscular contraction due to the disease. 

Lumbar Puncture. — If a long aspirating needle be 
introduced into the cavity of the spinal column between 
the third and fourth lumbar vertebrae, which space is 
on a level with the crests of the ilia, some of the spinal 



154 FEVER NURSING 

fluid may be removed. This fluid is clear in cases of 
tubercular meningitis, but cloudy in epidemic cerebro- 
spinal meningitis. Culture for detection of the germ 
may also be made from this fluid. 

Lumbar puncture is also one method of treatment. 

Care and Management. — As far as the treatment of 
this disease by medicines is concerned, it has been said 
that the mild cases need none and the malignant one 
will not react to medication. 

The first requisite is isolation of the patient. The 
room should be large, cool, airy, and well darkened. 

The diet should consist of milk, eggs, broths, gruels, and 
predigested forms of beef. Water may be freely given. 

The secretions from the nose, throat and mouth 
should be carefully collected and immediately burned. 
The dishes of the patient should not be taken from the 
sickroom, and should only be used by him. 

For the headache, which is present in nearly all cases 
and is generally of a severe type, the application of the 
ice-bag to the head is the only local measure of any 
merit. Ice-bags to the head and along the spine serve 
three purposes: they relieve pain and headache; they 
prevent excessive fever and lower the nervous phe- 
nomena, and they retard the formation of effusions. 

If the temperature be high, cold sponges or baths 
may be used as in typhoid fever. Warm baths at a 
temperature of io4°F. have been recommended to lessen 
the tendency to spasms and convulsions. 

Blistering agents to the nape of the neck early in 
the attack lessen the formation of meningeal effusions. 

Vomiting is best treated by thoroughly emptying the 
bowels and placing the patient on a diet of peptonized 
milk exclusively. 



EPIDEMIC CEREBROSPINAL MENINGITIS I 55 

Convulsions may be stopped by hot baths, and if 
very severe, by inhalations of ether or chloroform. 

Convalescence is slow as a general rule, but may be 
hastened by instituting a diet of very nutritious foods, 
by administering tonics of iron, gentian, arsenic, etc., 
and by abundance of fresh air and sunshine. The 
sickroom and its contents should be thoroughly dis- 
infected. 



CHAPTER XVIII 
ACUTE EPIDEMIC ANTERIOR POLIOMYELITIS 

Synonyms. — Spinal infantile paralysis, infantile 
paralysis, epidemic poliomyelitis, acute atrophic spinal 
paralysis, amyotrophic spinal paralysis. 

Definition. — A disease occurring chiefly in children, 
and characterized by an acute febrile onset, with se- 
quential flaccid motor paralysis and muscular wast- 
ing, and without prominent sensory symptoms. 

Etiology. — This disease usually occurs in children, 
especially before the fourth year. Both sexes are equally 
affected. It has followed exposure to the elements, 
cold and dampness, and has been subsequent to 
traumatism. Some authorities say it mechanically 
follows a plugging or thrombosis of the anterior spinal 
artery. Others say it depends entirely on a specific 
bacterial origin. In a study of a great number of 
cases in epidemics, nothing certain as to the causative 
agent has been determined. Harbitz, as a result of 
the study of nearly 1200 cases of acute anterior polio- 
myelitis occurring in epidemic form in Norway in the 
years of 1903 to 1906, comes to the conclusion that this 
disease is due to a micro-organism whose probable 
atrium is the digestive tract, and that the nervous 
system becomes infected either by way of the lymphatic 
vessels or by the blood current. 

Anatomical Seat of Lesion. — The lesion of this affec- 
tion, as its name would indicate, is situated principally 

156 



ACUTE EPIDEMIC ANTERIOR POLIOMYELITIS 157 

in the gray matter of the anterior horn of the spinal 
cord, being most intense in the cervical and lumbar 
regions. The pathological findings are not entirely 
confined to the anterior horns, but the pia mater, the 
pons, medulla, and even the cerebral substance have 
been involved, but to a lesser extent than the cord. 
As the anatomical seat of the lesion is principally in 
the anterior horn, the resulting symptoms expected are 
those of a purely motor character, with flaccidity, loss 
of reflexes, muscular wasting and absence or decrease 
of electrical response. 

Symptomatology. — The disease, as a rule, begins 
abruptly with a rapid rise of temperature, accompanied 
by nausea, vomiting and diarrhea or constipation. 
Excessive sweating is often a premonitory symptom 
of great frequency. Pain is a very common symptom. 
The acute prodromal period may last from several days 
to two weeks. The paralysis usually occurs, or, rather, 
is discovered, on the third or fourth day. It is interest- 
ing to note the prodromal symptoms which occurred 
in some of the prominent epidemics. Collins, in a report 
of 500 cases in the New York epidemic of 1907, found 
that 29 per cent, of the cases were characterized by 
high fever, and that the duration of the fever was from 
one to four days in a majority of the cases, and very 
infrequently longer than one week. Vomiting occurred 
in about 30 per cent, of the cases, diarrhea in 10 per 
cent., constipation in 17.6 per cent., retention of urine in 
7.4 per cent, of the cases. Fetid stools were noted in 
cases in which neither constipation nor diarrhea was pres- 
ent. Three symptoms to which especial attention was 
directed were abdominal paralysis, retention of urine 
and constipation. The common symptoms were som- 



158 FEVER NURSING 

nolence, stupor, rigidity of the neck, immobility, scream- 
ing and insomnia. V. P. Gibney, in a report of the same 
epidemics, as a result of studying 100 cases, found diar- 
rhea and vomiting in 19 per cent., vomiting and consti- 
pation in 11 per cent. Starr's findings in the same epi- 
demics were that the disease uniformly began with febrile 
manifestations, and usually with vomiting, general sweat- 
ing, severe pains in the limbs, with diarrhea on the sec- 
ond or third day. 

Motor Symptoms. — Paralysis. Motor paralysis forms 
one of the most important symptoms of infantile paral- 
ysis. The paralysis occurs after or during the abate- 
ment of the severe premonitory symptoms, usually in 
the course of several days, although it is not rare for 
these signs to occur very early; the patient retiring at 
night in a normal condition, and in the morning being 
affected with an extensive paralysis. 

The distribution and the extent of the paralysis varies 
exceedingly. It may involve only the muscles of a 
single group, or it may be of the hemiplegia, diplegia 
or monoplegia type, depending on the extent of damage 
in the cord. The primary paralysis is generally much 
more extensive than that which will be permanent. It 
gradually subsides until only those groups of muscles 
presided over by the affected areas in the cord remain 
paralyzed. 

From the knowledge of anatomy and physiology of 
the cord, we perceive that fibers from the anterior root 
cells leave the cord by way of the anterior nerve roots, 
and that these roots do not supply single peripheral 
nerves but, by means of the plexuses, their fibers are 
distributed to a number of nerves; thus, the anterior 
horn fibers are found not to supply anatomical groups 



ACUTE EPIDEMIC ANTERIOR POLIOMYELITIS 1 59 

of muscles, but physiological or like-functionating groups 
of muscles. Therefore, lesions of the anterior horns of 
the cord produce a paralysis of synergetically acting 
muscles, thus differing from nerve and brain lesions which 
affect anatomical groups of muscles. In anterior horn 
disease, two contra-functionating muscles lying side by 
side and supplied by the same nerve are differently 
affected, the one being actionless and the other normal. 

The muscles of the lower extremity are more often 
affected than those of the upper extremity, the extension 
muscles being more often paralyzed than the flexors. 
Collins and Romeiser, in an analysis of 500 cases of spinal 
infantile paralysis, found the distribution of paralysis 
as follows: Leg, 43.2 per cent.; both legs, 26.8 per cent.; 
arm, 7.2 per cent.; both arms, 1 per cent.; triplegia, 5.4 
per cent.; quadriplegia, 6.4 per cent.; homolateral, 4 
per cent.; crossed, 2.6 per cent.; cranial nerve, 7 per cent. 
The frequency of the parts paralyzed: 1 — leg; 2 — legs 
only; 3 — arm; 4 — quadriplegia; 5 — triplegia; 6 — hemi- 
plegia; 7 — contralateral; 8 — both arms only. The func- 
tion of the sphincters are very seldom affected. 

Convulsions may occur during the prodromal stage, 
but are not common thereafter. 

Reflexes. — As in all cases of inferior component paral- 
ysis, the reflex action is lessened or altogether abolished, 
depending on the extent of injury to the anterior horn 
cells of the respective reflex arcs. 

Muscle Tone. — As the anterior horn cells preside over 
the tonicity of the various muscles, an affection of this 
part of the cord produces a decrease or loss of muscular 
tone. Flaccidity of the muscles is very characteristic 
of infantile paralysis. The parts become loose and the 
joint action flail-like. 



l6o FEVER NURSING 

Gait. — In anterior poliomyelitis, as the child begins 
to use the lower limbs in ambulation, a peculiar form of 
gait is noticed. As said above, the limbs are loose and 
the joints have a flail-like action; the legs are laxly and 
passively thrown forward, or may even be dragged along. 

Sensory Symptoms. — From the confinement of the 
lesion to the anterior horn or motor portion of the cord, 
sensory symptoms are not to be expected, and this is the 
case, although in the prodromal stage severe pains in the 
limbs are not uncommon, but are probably due to the 
febrile or toxic disturbances as in the other infectious 
diseases — typhoid fever, diphtheria or scarlet fever. 

Anaesthesia and other sensory disturbances are exceed- 
ingly rare. If the lesion of the anterior horn encroach 
on the pain tracts which cross in the central gray matter, 
then painful sensations may occur in the affected parts. 

Trophic Disorders. — Muscular Atrophy. The anterior 
nerve cells preside over the nutrition of the muscles 
with which they are in relationship, therefore a lesion 
affecting these cells as does anterior poliomyelitis pro- 
duces muscular wasting. In this disease the muscular 
atrophy often reaches an extreme stage. 

Bone Dystrophies. — The bones in some cases are 
also affected. Their growth is retarded and in some 
cases entirely brought to a standstill. This, together 
with the muscular atrophy, makes the affected limb 
much smaller than its unaffected partner, both in 
length and bulk. 

Contractures. — Owing to the weakness of the 
affected muscles, there is great overaction on the part 
of the opposing muscles, thus producing various de- 
formities and contractures, such as the various forms 
of clubfoot, equinus positions, flattened arches, recurv- 



ACUTE EPIDEMIC ANTERIOR POLIOMYELITIS l6l 

ing of the knee joint, deformities of the spine and 
shoulder and wrist. 

Owing to vasomotor disturbance, the affected parts 
are cold, mottled and discolored. Bed sores do not 
develop. 

Electrical Reactions. — As the inferior component is 
involved, changes in electrical reactions are prominent. 
The parts very early give a lessened response to f aradic 
stimulation, and the characteristic reactions of de- 
generation rapidly make their appearance. 

Diagnostic Features. — The diagnosis of anterior 
poliomyelitis, as a rule, should not be exceedingly dif- 
ficult. Its prodromal febrile onset, followed by a 
purely motor paralysis of the inferior component type, 
should positively stamp it. Characteristic is the 
paralysis of physiological or like-functionating groups 
of muscles, with naccidity, rapid atrophy of the muscu- 
lature, loss of reflex action in the affected parts, pres- 
ence of an altered electrical response with the re- 
actions of degeneration, with the absence of sensory 
symptoms. 

Care and Management. — The States of New York 
and Massachusetts have added this disease to the list 
of communicable diseases. It may be well to insert 
here a few excerpts from a circular issued by the New 
York State Department of Health: 

Epidemic poliomyelitis has been added to the list of 
communicable diseases, the occurrence of which is re- 
quired by the State Department of Health to be re- 
ported to local health officers, and by them to the 
department. 

Since 1881 medical literature has contained reports 
of outbreaks of infantile paralysis; during the last five 
11 



1 62 FEVER NURSING 

years these outbreaks in several parts of the world 
have increased in frequency out of proportion to the 
increased interest shown in the disease. That is, the 
increased number of reports cannot be attributed 
wholly to more accurate diagnosis or greater care in 
reporting the cases. 

The disease is found to be more prevalent in cold 
than in warm countries, and more cases have been 
reported from the northern part of the United States 
than from any other part of the world. It occurs 
mostly in children, but adults have been afflicted. In 
1907 there was an epidemic of 2500 cases in New 
York, the largest ever reported. It generally begins 
late in the summer, and ends after a few hard frosts 
in October. 

Laboratory workers have already demonstrated that 
infantile paralysis is an infectious disease, caused by 
a living organism so small that it can pass through 
a bacterial filter. It is thought to be most contagious 
during the early, or febrile, stage of the disease. Most 
of the laboratory study has been made upon monkeys, 
who acquire the disease by inoculation of an emulsion 
of certain tissues from a human being dying of the 
disease, and from affected monkeys. 

With a view to the prevention of the disease, the 
State Department of Health expects that every case 
discovered will be quarantined. Some local boards of 
health have already passed an ordinance requiring a 
quarantine in this disease, and such action is approved 
by the department. The discharges from a patient — 
stools, urine, sputum — should be disinfected. 

The patient should be isolated, in order to protect 
other members of the family and the community in 



ACUTE EPIDEMIC ANTERIOR POLIOMYELITIS 1 63 

general. The excretions, especially those from the 
nose, mouth, kidneys and bowels, should be thoroughly 
disinfected, as described under typhoid fever. The 
bowels should be thoroughly evacuated for two rea- 
sons: first, constipation is very common; second, 
whether constipation or diarrhea prevails, the bowel 
content is often fetid. The result may be attained 
by the use of castor oil, enemata, or both. The child 
should be urged to freely partake of liquids, especially 
water, and if because of vomiting or other reasons 
sufficient water is not taken, it may be given by the 
rectal saline drop method, which acts very favorably 
and increases the functions of the kidneys. The skin 
may be made active by means of hot packs or hot 
air baths. 

The diet, as in all febrile conditions, should be light 
and nourishing. Milk in one or more of its many 
modified forms should be the basis of feeding. Cereal 
gruels, albumen, water broths, ice cream, gelatine and 
fruit juices may be used to vary the diet. 

High fever should be met with one of the many 
hydrotherapeutic measures described in succeeding 
chapters. An ice-bag to the head may quiet delirium. 
A hot bath will often relieve muscular spasm. As the 
disease progresses from the acute stage into the per- 
manent stage, the use of electricity, massage, passive 
and active exercise and baths may be employed to help 
the return of normal muscular and nerve functions. 

The Great Ormond Street Hospital for Children, in 
London, issues a small circular regarding the care 
of paralyzed limbs, which I herewith add, in part: 

Clothing. — The paralyzed parts must be kept warm 
day and night. 



1 64 FEVER NURSING 

Knitted woolen stockings to come up above the knees 
must be worn. 

If these do not keep the limbs warm, woolen over- 
alls must be worn outside the stockings. 

The overalls must be lined, if necessary, with cotton 
wadding quilted to them. 

For the night, a flannel sack made the shape of the leg, 
coming up to the top of the thigh and lined with 
cotton wadding, is best. 

Rubbing. — This must be done for a quarter of an 
hour twice daily. 

Lay the child on a bed. 

i st. Rub the paralyzed leg from the foot right up to 
the top of the thigh. Rub upward only. Put the 
broad part of your hand on the back of the child's 
leg. In rubbing the thigh, put your hand first on the 
back of the thigh, and afterward on the front, but 
always rub upward, and be sure to go as high as the 
child's loins. While rubbing with your right hand, 
hold the child's foot with your left. Use for rubbing 
any kind of oil. 

2d. Take hold of the child's leg with your two 
hands just above the ankle. Rub around the leg with 
your two hands in opposite directions, as though you 
were wringing out sheets. Work up the leg and thigh 
from the foot to the top of the thigh, in the above 
manner. 

3d. Flip every part of the leg and thigh with your 
fingers, so as to make the whole of the limb quite red 
and warm. 

Rub gently up and down all over. This will take away 
the stinging which was left by the last movement. 

Baths. — Once a day let a large jugful of hot water, 



ACUTE EPIDEMIC ANTERIOR POLIOMYELITIS 1 65 

containing two handfuls of salt, be poured down the 
leg and thigh. 

Then pour about half the quantity of cold water 
over the leg and thigh. 

Then rub thoroughly with a towel until the limb is 
perfectly warm and dry. 



CHAPTER XIX 
LOBAR PNEUMONIA 

Definition. — Lobar pneumonia is an acute infec- 
tious fever, characterized by inflammation of the lungs, 
with symptoms of general toxemia. The lesion is due 
to a specific bacterium — the pneumococcus. 

Synonyms. — Croupous pneumonia, fibrinous pneu- 
monia, pleuropneumonia, pneumonitis, lung fever. 

Etiology. — The exciting cause is the pneumococcus. 

Predisposing causes are the Fall and Winter sea- 
sons, exposure to the elements, cold and rain. Elderly 
and enfeebled persons are very susceptible. The use 
of alcoholic beverages to excess, lowering the resist- 
ance of the individual, pre-existing diseases as diabetes, 
nephritis, typhoid fever, and injury to the thorax may 
precipitate an attack. 

The germ causing pneumonia is said to have been 
found in the mouths of sixty per cent, of individuals. 

Pathology* — The course of the pathologic events 
are divisible into three stages: 

First stage consists of engorgement or congestion 
of the lung. It lasts from twelve to thirty-six hours. 
If the patient dies in this stage, the lung will be found 
very red and when cut the blood drips from it. It 
crepitates when pressed between the fingers and when 
placed in water it floats midway. 

Second stage or the stage of red hepatization. The 
lung is very solid due to the great amount of fibrinous 

166 



LOBAR PNEUMONIA 1 67 

exudation, and resembles very much the consistency 
of the liver and is red in color. From these two facts 
the condition derives its name. 

The cut surface of a lung in this stage is granular 
and somewhat dry. There is no dripping of blood. 
When placed in water it sinks to the bottom. It does not 
crepitate on pressure. 

Third stage or stage of gray hepatization. The exu- 
date of the former stage is now undergoing certain 
degenerative changes and becomes gray in color and 
more fluid. When placed in water it floats. 

Symptoms. — -The onset of lobar pneumonia is usu- 
ally abrupt. There may be a day or two of malaise, 
headache and loss of appetite, but as a rule it begins 
suddenly with a chill. The chill is very severe and 
pronounced, sometimes lasting from twenty to thirty 
minutes and so vigorous as to shake the bed if the 
patient be in bed at the time. The temperature rises 
rapidly and to a high point (104 to io6°F.); there is a 
sharp stabbing pain in the side, especially pronounced 
on coughing or breathing deeply, and is due to an 
acute pleurisy. 

Cough appears early and is short and suppressed 
because of the pain it causes. The sputum is very 
characteristic in the first part of the disease. It is 
scant in amount, very viscid, and of a reddish, rusty 
color. If the cup in which the patient expectorates be 
inverted, the sputum, on account of its viscidness, 
clings to the walls of the cup and does not fall out. 

The respirations become very rapid and at times 
irregular. 

The face is flushed and the flush is said to be greater 
on the side in which the pulmonary lesion is situated. 



105 FEVER NURSING 

Herpes labialis is very common in this disease. The 
alae nasi dilate on inspiration, and the grunt on expira- 
tion is more or less characteristic. 

The tongue is coated, the mouth dry, nausea and 
vomiting are not uncommon. 

The urine is scant in amount, highly colored, of a 
high specific gravity, and contains a small amount of 
albumen. 



DATE 








































108 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


108 


107 
106 
105 










































































107 
106 
105 
104 
103 
102 
101 
100 
99 
98 
97 


104 
103 
102 

101 
100 
99 
98 
97 























































































































































































































































































































































































Fig. 14. — Temperature chart of lobar pneumonia. 

Fever. — The temperature, as said above, becomes 
rapidly high; after reaching its fastigium it usually 
remains at a common height for a few days, and may 
then suddenly fall by crisis. Two or three days before 
the crisis there may be a pronounced fall in the tem- 
perature, but it soon reaches its height again. This 
fall is known as the pseudocrisis. 

It has often been noted that just before the occur- 
rence of the crisis the patient, who has hitherto been 
restless, will fall into a quiet sleep — -the precritical 
sleep. 



LOBAR PNEUMONIA 1 69 

The crisis is accompanied by a drenching sweat after 
which the patient becomes very comfortable. 

Nervous Symptoms. — -In children and young persons 
convulsions may usher in the disease. Delirium of an 
active type may occur, especially in persons of alcoholic 
habit. 

Varieties. — Infantile Pneumonia. Instead of be- 
ginning with a chill this type in many instances is 
ushered in with a convulsion. Vomiting is of frequent 
occurrence. The course is not regular. 

Pneumonia in the Aged. — The temperature is not as 
high as in young adults. The pulse is rapid, feeble, and 
irregular. The temperature usually falls by lysis. It 
has been a very common occurrence in the author's 
practice to have elderly patients who did not cough or 
expectorate a particle of sputum during the entire course 
of the disease. 

Wandering Pneumonia. — 'This form moves from 
place to place. It may start in the lower lobe of one 
lung and then migrate to the other lung. If the course 
be slow and it resolve in one place while it is acute in 
another, the prognosis is not so bad. 

The typhoid form is of a nervous type. The tongue 
is dry, delirium is common, and the usual toxic symp- 
toms seen in typhoid fever are present. 

Central Pneumonia. — In this form a patch of cen- 
trally located lung is involved. The physical signs are 
absent at first. 

Complications. — 'Pleurisy is of very frequent occur- 
rence as the dry form. Empyema frequently follows 
and may be serious. 

Pericarditis is not uncommon. I have seen a most 



170 FEVER NURSING 

grave pericarditis with great effusion follow a pneu- 
monia of a very mild type. 

Endocarditis is frequent, especially in pneumonia in- 
volving the left lung. 

Other complications are meningitis, edema of the 
lungs, delayed resolution, nephritis, and neuritis. 

Prognosis depends on age; under twenty months 
the disease is usually fatal. Between the ages of two 
and eight years it is favorable if the child be not rick- 
ety. It is very favorable in young adult life, but be- 
comes a serious and grave disease in elderly people. 

Toxemia alters the prognosis. Severe toxemia is 
always serious. 

Situation. — 'Central pneumonia is serious and next 
in gravity is involvement of the upper lobe. 

Symptoms. — 'Active delirium causes exhaustion. 
Low temperature with rapid pulse is grave. Pul- 
monary edema is usually a forerunner of a fatal 
termination. 

If the crisis be prolonged beyond the ninth day and 
resolution be delayed, be suspicious of tuberculous 
involvement. 

Course. — The disease may terminate by resolu- 
tion and absorption and excretion of the exudate. 
Resolution may be slow and delayed but eventually be 
complete. Chronic interstitial pneumonia may result. 
Gangrene or abscess of the lung may follow, with fatal 
termination. 

Care and Management. — The germs of pneumonia, 
as those of tuberculosis, are probably distributed in 
the dry dust of the air, and thus gain entrance to the 
respiratory tract of the human organism. These germs, 
if they be particularly virulent or if the resistance of 



LOBAR PNEUMONIA 171 

the individual be lowered, will begin to multiply. It 
will thus be seen that if a person is to be protected 
from contracting pneumonia, he must maintain his 
bodily resistance and not expose himself to such de- 
bilitating influences as cold, wet, poorly ventilated apart- 
ments, etc. 

Pneumonia is also without doubt a communicable 
disease. 

General Management. — The patient should be in a 
well- ventilated, large room with plenty of air. He 
must remain quietly in bed and not be allowed to leave 
it until at least ten days after the crisis. Absolute rest 
is a necessity of prime importance; the patient is not 
to exert himself in any way. There are many exam- 
ples of a sad and fatal ending of a pneumonia patient 
who seemed in excellent condition, but who, thinking 
himself strong, moved suddenly in bed and caused a 
fatal dilatation of the heart. 

The diet should be light, very nourishing and chiefly 
liquid. Milk will form the main article of diet and 
may be supplemented daily with a raw egg or two, 
albumin water, and some standard preparation of pre- 
digested beef. After the crisis semi-solid and solid 
articles of food may be given gradually. 

The bowels should be kept open by enemata. If the 
temperature be high, nervous symptoms prominent, 
and the heart action weak, hydrotherapy should be 
resorted to. Baths should not be given as freely as 
in typhoid fever. Three or four in twenty-four hours 
are sufficient. The water used should be about 85 F. 
or 90 F. 

The continuous use of the ice-cap is a most excellent 
means of applying cold, and is agreeable and com- 



172 FEVER NURSING 

fortable to the patient. An occasional alcohol rub will 
also serve its purpose. 

Sleeplessness is one of the most troublesome symp- 
toms of pneumonia. If the physician does not care to 
resort to hypnotics for certain reasons, then local meas- 
ures must be used. A hot drink, an ice-bag to the 
head, a mustard foot bath, or a tepid sponge are all 
serviceable. 

For the severe pain in the side, usually prominent in 
the beginning of the attack, nothing is more useful as 
a local application than an ice-bag. If the patient ob- 
ject to this, a mustard paste may be substituted or hot 
fomentations. 

The heart is the one organ on which the bulk of the 
burden falls. It is to this organ that a most careful 
vigilance must be directed. If the rate become high, 
the action irregular and tumultuous, or the rhythm 
altered, the nurse will understand that the organ is 
beginning to be affected and the physician's attention 
should be called to it immediately. 

For a tumultuous heart the ice-bag is of most valu- 
able service. 

During the crisis support and stimulation is of para- 
mount import. 

The drugs generally used in this disease for heart 
stimulation are digitalis, strychnine, alcohol, and atro- 
pine. If a very rapid stimulation be necessary as at the 
crisis, aromatic spirits of ammonia or the compound 
spirits of ether may be given every hour or two in 
half-dram doses, well diluted. 

If cyanosis and dyspnoea are present, then oxygen 
may be administered. In profoundly toxic cases, the 



LOBAR PNEUMONIA 1 73 

use of normal saline solution as a hypodermoclysis is 
very useful. 

It may very rarely fall to the lot of a nurse to per- 
form or assist at a venesection. This is generally per- 
formed on the front of the arm at the elbow joint. 

The part is first thoroughly cleaned as for a minor 
operation. A rubber bandage or tourniquet is placed 
around the arm above the elbow, causing the veins 
below to become very prominent. An incision one- 
half inch in length is made over the site of one of the 
veins, generally the median cephalic. When the an- 
terior wall of the vein is incised the flow of blood is 
free, provided the tourniquet is not so tight as to inter- 
fere with the arterial supply of the forearm. When 
sufficient blood has been removed, from one-half to 
one pint, a sterile pad is placed over the incision and 
a bandage firmly applied. The dressing need not be 
removed for five or six days. 

Management of Pneumonia in Children. — The 
care of a child ill with pneumonia differs somewhat 
from that of an adult. The child should be confined to 
bed in a large, airy room. The temperature should be 
equable (about 68° F.). Quiet should prevail; loud 
talking within the room or in hearing distance of the 
patient is to be prohibited. Fresh air and ventilation 
are of prime importance. 

Dr. Wm. P. Northrup of New York has said: "If 
you wish to kill a child with pneumonia, then place the 
crib in a far corner of the room with a canopy over it. 
Have the temperature of the room 8o° F. Have many 
gas jets burning, shut the doors and windows, place a 
large poultice around the child's chest, and have a few 
friends in the room." 



174 FEVER NURSING 

The diet should consist of milk only. If the child be 
very young, the milk should be modified as given 
in the chapter on "The Diet of the Sick." Special care 
must be given to the diet. Milk very frequently causes 
distention of the abdomen which seriously interferes 
with the action of the heart. Water should be freely 
given. 

The bowels must be evacuated at least once a day. 

Fever in a child is not as significant as in an adult. 
Often it need not be treated, unless it mounts very 
high or is accompanied by restlessness and nervous 
phenomena, when tepid sponges and cool packs will be 
very serviceable. 

A thick bath towel is immersed in water at 85°F. 
to 90°F., and then wrapped about the child's chest 
and trunk, and a light blanket thrown over the child. 
If in ten minutes the results are not satisfactory, repeat 
the procedure, using water which is a little cooler. 

Cold and clammy feet are often seen in this class 
of cases. In these patients a hot foot bath is of great- 
est benefit. Watch the feet! Counter- irritation to the 
chest in the form of a weak mustard paste is often 
serviceable. 

Convalescence in pneumonia, as a rule, is very 
rapid and may be greatly enhanced by nourishing diet 
and tonics. 



CHAPTER XX 
DIPHTHERIA 

Diphtheria is an acute contagious, infectious dis- 
ease, always caused by the same germ known as the 
Klebs-Loffler bacillus. The contagion is given off from 
the patient, principally in the breath through the nose 
and throat and also by excretions from infected parts, as 
pus from ear discharges. Diphtheria is given directly 
by the patient or may be carried by a third person, or 
may be transported on toys, clothing and dishes. It 
may be given by a person not suffering from the disease 
but who harbors the diphtheria bacilli in his throat. 
These persons are called diphtheria carriers. The dis- 
ease may be spread by infected milk, the milk ob- 
taining the contagion from the pails or hands of the 
milkers, or the cows may be suffering from the disease in 
the form of "chapped teats." Children who frequently 
suffer from common sore throat are more liable to con- 
tract diphtheria when exposed. Children between the 
ages of one and eight years are most susceptible to the 
disease, and it is a well-known fact that members of cer- 
tain families are more apt to take the disease than 
others. 

Etiology. — The existing cause is the specific bacil- 
lus mentioned above. Predisposing causes are expo- 
sure to cold and wet, tonsillitis and pharyngitis, which 
lessen the resistance of the mucous membrane. The 
time of greatest susceptibility is between the ages of 

i75 



176 FEVER NURSING 

six months and six years. Adults are not so liable to 
contract this disease as are children. The force of 
the infection is not always equal; some epidemics are 
more severe than others, and some individuals are 
attacked more vigorously than others. 

The bacilli themselves usually remain at the site of 
the local lesion, but the toxines which they produce are 
absorbed and give rise to the general toxic symptoms. 

The tonsils afford an excellent residence for the 
germs, as the crypts of the tonsils usually contain ma- 
terial upon which the bacilli may subsist and also pro- 
vide two important requisites to the multiplication of 
bacteria, namely, heat and moisture. 

At first only a hyperemia of the mucous membrane 
is produced, but later an exudation is thrown out 
which sinks into the tissues and is followed by a ne- 
crosis of the superficial layers, forming a false or 
pseudomembrane. Great edema of the parts and ab- 
scesses may develop. 

This pathologic process just described may occur on 
any mucous membrane, as of the tonsil, pharynx, lar- 
ynx, nasal cavity, esophagus, stomach, vagina, con- 
junctiva, etc. 

The membrane is at first gray but soon becomes of 
a dirty brown color. It cannot be readily removed, 
and if taken off leaves a raw, bleeding surface. 

Degeneration of the nerves, heart, kidneys, and liver 
are common. 

Symptoms. — Diphtheria may affect the tonsils, 
throat, larynx, nose or even the skin it if be broken. 
The most common places are the throat and tonsils, the 
larynx and the nose. Probably the first symptom of 
which the child complains is soreness of the throat, 



DIPHTHERIA 1 77 

especially when he attempts to swallow. Other symp- 
toms may appear three or four days before the sore 
throat attracts attention, but are usually attributed to 
other causes until the characteristic throat symptoms 
begin. Principally among these prodromal symptoms 
are peevishness, irritability, chilliness and general 
pains over the body. Sore throat soon occurs but even 
then it may be thought only a simple tonsillitis. The 
throat is first reddened, the small specks appear and 
finally the membrane or skin is seen. This membrane is 
not confined to the tonsil only, but rapidly spreads over 
the soft palate, uvula or other parts of the throat. 
The membrane is at first white and not easily removed 
or rubbed off as a simple tonsillar exudation usually is. 
Even though many signs be present, diphtheria may not 
as a certainty be told until a little of the membrane is 
examined and the true bacillus or germ is found. The 
fever continues and as a rule does not go excessively high, 
often not as elevated as in simple tonsillitis. The 
glands of the neck, especially those beneath the angle of 
the jaw, may become enlarged. The urine may get dark 
and scanty. In small children the breathing is usually 
noisy. The membrane spreads during the first few days 
and then begins to loosen and disappear. The course is 
usually ten days to two weeks. The heart is very sus- 
ceptible to the poisons of diphtheria and may become 
permanently damaged. The nervous system is also 
easily affected and various forms of muscular paralysis 
occur. Principally among these is loss of power in 
the muscles of the soft palate and throat and shows itself 
by inability of the patient to properly swallow; liquids 
instead of passing down into the stomach come back 
through the nostrils, also he loses the ability to gargle 



178 FEVER NURSING 

and " spells" of choking may occur. Paralysis may af- 
fect the larynx and produce changes in the voice, even 
extending to complete loss of voice. The eyes, arms and 
legs may become involved. 

Diphtheria of the Larynx. — Next to diphtheria of the 
throat or fauces, which has just been discussed, diph- 
theria of the larynx is most frequent. This condition 
is also known as true membranous croup, but should not 
be confused with simple croup or spasmodic laryngitis. 
Laryngeal diphtheria may begin as such or, as is more fre- 
quently the case, it follows the throat diphtheria. The 
first sign to direct one's attention to this disorder is the 
quality of the voice. The voice may become husky, 
hoarse or weak. A peculiar brassy quality is very com- 
mon. A whisper may be all that the patient can pos- 
sibly effect. Another characteristic is the laryngeal 
stridor, which is a sound hard to describe, being like air 
forced through a narrow place. Breathing may become 
very difficult. The other symptoms are similar to those 
of pharyngeal or throat diphtheria. Laryngeal diph- 
theria is much more serious than the simple pharyngeal 
form. 

Diphtheria of the nose is the third frequent form of 
diphtheria. This may occur alone but usually accom- 
panies one of the other forms. There is an abundant 
discharge from the nostrils of a pus or blood combina- 
tion. The skin over which the discharge passes soon 
becomes red and irritated. Other general symptoms 
are like those of pharyngeal diphtheria. 

Diphtheria may run a very mild to a very severe 
course. At the beginning of the disease it is impossible 
to say what will be the result. A simple pharyngeal 
form may progress into a most grave laryngeal form with 



DIPHTHERIA 1 79 

many complications. However, since the entrance of 
the antitoxin treatment the mortality from diphtheria 
has fallen very greatly; in fact, nowadays we very seldom 
see the malignant forms of this disease that were common 
before the days of antitoxin. 

Complications and Sequelae. — Hemorrhages may oc- 
cur in the skin, kidneys, or nose, due to a fatty de- 
generation of the vessel walls. 

Pneumonia is a very common complication. 

The toxines of diphtheria seem to have an especial 
affinity for the heart and cardiac degenerations are of 
frequent occurrence. 

The kidneys are also attacked by the toxin e and 
Bright's disease often complicates diphtheria and shows 
itself by an increase of albumen in the urine, and the 
presence of casts and blood. 

The enlarged cervical glands may soften and ulcerate. 

The most important sequelae are the nerve degenera- 
tions with their accompanying paralyses. The nerve 
sequelae occur, as a rule, after convalescence has ad- 
vanced for two or three weeks. 

When the nerves of the pharynx and surrounding 
structures are involved there results a series of char- 
acteristic paralyses. The muscles of the pharynx and 
soft palate, as a rule, are the first to suffer. The voice 
takes on a nasal tone, food given by the mouth re- 
gurgitates through the nose, swallowing is difficult 
and impeded. 

Other nerves of the body are also affected. There 
may be strabismus, ptosis, loss of power of accommo- 
dation, and facial paralysis may occur. The muscles 
of the neck may be affected and weakened, when the 
head will lean to one side or roll about on the shoulders. 



l8o FEVER NURSING 

The upper extremities are rarely involved. 

The legs may be affected and the knee jerks dimin- 
ished or lost. 

Prognosis. — This depends on the early use of anti- 
toxin and the complications. Before the use of anti- 
toxin, the mortality was from forty to seventy per cent. 

Mortality of cases treated with antitoxin on first 
day, i per cent. 

Mortality of cases treated with antitoxin on second 
day, 4.3 per cent. 

Mortality of cases treated with antitoxin on third 
day, 14.2 per cent. 

Mortality of cases treated with antitoxin on fifth 
day, 19 per cent. 

Involvement of the larynx, complications of the 
heart and kidneys are very grave. 

Transmission. — The excretions from the nose and 
mouth are loaded with infection. Therefore, they 
should be carefully collected, and not thrown on the 
carpet or placed in handkerchiefs and allowed to lie 
around. These excretions when dry become pulver- 
ized and are then suspended in the air and inhaled, 
thus spreading the disease. During the coughing spell 
the excretions may be discharged into one's face. 

The infection may also be conveyed on eating uten- 
sils, pencils, clothing, etc. The germs may linger in 
the throat for weeks after the disease subsides. 

Care and Management. — After the administration 
of the antitoxin there is little to be done besides pre- 
venting the spread of the disease, treating the disease 
locally, attending to the comfort of the patient, and 
being prepared to combat complications should they 
arise. 



DIPHTHERIA l8l 

Prevention of the spread of the disease is very im- 
portant. It is hardly necessary to say that absolute 
isolation of the patient is the first requisite. Members 
of the family are not to be allowed in the patient's 
room. Children in the same house with a patient suf- 
fering from diphtheria are not to attend school. All 
persons in the house, or those who have been exposed to 
the disease, should be immunized by small doses of 
antitoxin (500 units). If objection be made to this, 
then at least those who have never had the disease 
should be protected by this immunizing dose of 
antitoxin. 

The room in which the patient is to lie should be 
large, airy, light, and capable of being ventilated. If 
a room with a fire-place can be used, it would afford 
better ventilation. All furniture, hangings, etc., that 
are not essential to the comfort of the patient and nurse 
should be removed. A comfortable bed, a large table, 
and one or two chairs are all the furniture necessary. 

The temperature of the room should be kept equable, 
at about 65 F. Avoid having the patient exposed to 
draughts. A separate set of eating utensils should be 
used in the sickroom. 

Allow no uncovered dishes of food or medicines to 
remain about the room. When the patient has drunk 
all the milk he cares to, do not place the glass contain- 
ing the residue of milk on the table, but remove it at 
once and cleanse it. 

Always have a basin of some antiseptic solution 
handy, preferably corrosive sublimate solution (1 to 
1000). 

Keep the floor and furniture scrupulously clean. If 
dishes are washed in the general kitchen, they should 



1 82 FEVER NURSING 

be thoroughly immersed in a strong antiseptic solution 
before leaving the sickroom. Do not place metallic 
dishes, etc., in solutions of corrosive sublimate. 

Bedclothing and the patient's gowns should be fre- 
quently changed. Soak well in a strong antiseptic so- 
lution before sending them to the laundry. 

One person should care for the patient and all 
others, excepting the medical attendant, should be 
excluded from the sickroom. The person in charge 
should not mingle with other members of the house- 
hold; as in all contagious diseases, visitors should not 
be admitted to the house, nor members of the house- 
hold allowed to visit others. 

A few words to the nurse about the protection of 
herself will not be here misplaced. Always immerse 
your hands in an antiseptic solution after attending to 
the patient. If it be required of you to make local appli- 
cations to the throat or nose of the patient, be very 
careful as you are on dangerous soil. It is well to hold, 
or have held, a large square of glass (at least twelve 
inches square) between your face and that of the 
patient when making applications. When the patient 
coughs, which he is liable to do when you are making 
local applications to the throat, myriads of the germs 
may be expelled. 

Spray your nose and throat frequently with some 
antiseptic solution. Do not sleep or eat in the patient's 
room. Wear only clothing that may be easily laundered. 

The diet is the same as in any acute febrile disease, 
namely, milk, gruels, broth, etc. It is very important 
that food be given regularly and that the patient get 
a sufficient quantity, as the whole system is greatly de- 
pressed and nourishing and easily assimilated food 



DIPHTHERIA 1 83 

will help the system to overcome the action of the 
toxin es. 

The same care must be exercised in regard to the ex- 
cretions and secretions as in typhoid fever. In diph- 
theria the excretions of the nose and throat are of special 
importance as they are exceedingly virulent. Soft 
linen cloths or pieces of old muslin should be used for 
collecting the nasal and pharyngeal secretions. These 
cloths when soiled must be burned immediately and no 
attempt should be made to wash and use them again. 
Do not use cups for collecting the sputum, for in expec- 
torating in a cup more or less of the material is sprayed 
into the air. 

Local Treatment. — It is very important to keep the 
mouth, nose and throat scrupulously clean. This may 
be done by the judicious use of antiseptic solutions in 
the form of spraying, atomizing, swabbing, gargling, and 
douching. Solutions to be used for this purpose are 
numerous: boric acid, four per cent.; potassium per- 
manganate, 1 to 2000; and peroxid of hydrogen, 1 to 8. 

Local applications to the false membrane itself was 
a prominent part of the treatment before the days of 
antitoxin, but they are seldom employed now. 

General Treatment. — -The administration of diph- 
theria antitoxin holds first place by far in the general 
treatment of this disease. The initial dose of the anti- 
toxin must be of sufficient quantity. At least 3000 
units should be administered and repeated at short 
intervals until the required action is obtained. The 
danger is not in giving too much, but in giving too little. 

The use of antitoxin should be followed, in at most 
twelve hours, by a decrease in the severity of all symp- 
toms. The temperature is lessened, restlessness is 



184 FEVER NURSING 

quieted, sleep is oncoming, and the patient becomes 
brighter. The local manifestations of the disease show 
improvement, the swelling and edema of the mucous 
membrane are lessened. The edges of the false membrane 
begin to retract and to quickly disappear. 

The duration of the disease is shortened and the prog- 
nosis is greatly brightened. If any organic changes 
have taken place in the nerve fibers or the heart, these 
are not repaired by the giving of antitoxin, but their 
advance may be checked. 

Certain ill effects of but minor importance sometimes 
follow the administration of antitoxin, and are due 
not to the antitoxin, but to the horse serum of which 
it is composed. The nurse should bear in mind these 
ill effects so that if they occur, she will understand their 
cause. 

These complications may appear in the form of a 
rash, which is an erythema in character and may re- 
semble the eruption of scarlatina or of rubeola; or it 
may be of an urticarial nature appearing as small wheals 
like a mosquito bite, and may itch. The rash may 
occur within ten minutes or many days after the injec- 
tion of antitoxin. A complication may occur in the joints, 
characterized by swelling of the joint and more or less 
pain. The temperature may mount very high. 

These ill effects are not dangerous but, unless expected, 
may cause some confusion. 

Method of Administration of Antitoxin. — -The site of 
injection is elective: the femoral or gluteal regions, or 
preferably in the interscapular space. The area should 
be well cleaned with soap and water and then treated 
with an antiseptic solution and rinsed with sterile water 
to remove the antiseptic. Some physicians simply 



DIPHTHERIA 185 

clean the area with alcohol. The syringe and needle 
with which the antitoxin is to be given should be steril- 
ized. At present all the larger manufacturers of anti- 
toxin provide a sterile syringe and needle with the serum. 
The needle should be inserted as is a hypodermic needle, 
but more deeply, and the serum slowly injected. 

Fever, if high, is treated with cold sponges and baths 
as in other febrile disorders. 

The soreness of the throat and neck is best relieved 
by the application to the neck of an ice-bag. Small 
pieces of ice in the mouth are very useful in older 
patients. 

For swollen glands apply an ointment of ichthyol or 
belladonna. 

In laryngeal forms the air of the sick rooms may be 
moistened by means of a steam kettle; or rilling the room 
with the vapors from ten grains of burning calomel is 
useful. 

In the nasal form the nose should be irrigated with 
normal saline solution. 

Intubation was employed to a considerable extent be- 
fore the days of antitoxin. It is well for a nurse to 
know how to prepare a child for the operation, so in 
case she be called upon she will be acquainted with the 
methods. 

Fold a sheet or blanket until it is just wide enough to 
extend from the chin of the child to the feet. Wrap 
this about the patient so that the whole body except 
the head and neck is included. Have the arms of the 
child extended along the side of the body before applying 
this binder. The sheet should be applied somewhat 
tightly to prevent the child from struggling with the 
arms and legs. Pin the binder snugly, but do not have 



1 86 FEVER NURSING 

a bulky roll at the upper end as it will interfere with 
the operator. 

The nurse sits upright, preferably on a stool, placing 
the child's wrapped legs between her knees and hold- 
ing them very firmly in this position. With her hands 
the nurse grasps the child's elbows, having the head 
resting against her left shoulder. The object is to thor- 
oughly immobilize the child without interfering with 
its respiration or the operator's field of work. 

Another nurse stands behind the child and grasps its 
head firmly between her two opened hands; with her 
left hand she also steadies the mouth-gag which is 
placed in the child's mouth on that side. The patient 
is now in the best position for intubation. 

Feeding the intubated patient is the next perplexing 
problem. Swallowing is more or less painful and dif- 
ficult. Particles of food often enter the larynx and 
cause not only severe fits of coughing, but may also 
cause an expulsion of the tube during the paroxysm. 

There are several methods of feeding an intubated 
child. In the first method the child's head is placed 
lower than the level of the body and then fed slowly. 
Place the child on its back across the lap of the nurse 
with its head low. This may be accomplished by having 
a pillow under the child's buttocks, or by the nurse 
raising her knee on that side. Then feed the patient 
either with a spoon or from a nursing bottle. This is 
very awkward to the child at first, but it soon learns to 
swallow without difficulty or coughing. 

A second method is by passing a small rubber catheter 
through one of the child's nostrils, down the esophagus 
into the stomach. Care must be taken that the catheter 
does not enter the larynx and intubating tube. With a 



DIPHTHERIA 187 

small funnel inserted into the free end of the catheter, 
milk can be easily introduced into the stomach. 

If both of these methods fail, then rectal alimentation 
must be employed. 

Quarantine. — The patient should remain in bed ten 
days after the disappearance of the membranes, when 
the throat is examined for the presence of the diphtheria 
bacilli, which, if found, will prolong the period of quar- 
antine. If none are found by repeated examination, 
and all symptoms have disappeared, the child may be 
permitted gradually to resume its former mode of life. 

The room, all its contents, and the clothes of both 
patient and nurse must be thoroughly disinfected. For 
the method of disinfection see the chapter on Scarlet 
Fever. 



CHAPTER XXI 
ACUTE ARTICULAR RHEUMATISM 

Etiology. — 'The exciting cause of the disease is at 
present unknown. It is supposed to be of bacterial 
origin. 

Predisposing causes are exposure to cold and wet 
especially; it is more prevalent in damp seasons and 
after prolonged dry seasons. Early adult life is a pre- 
disposing factor, particularly between the ages of ten 
and thirty years. Occupations which expose the indi- 
vidual to the elements excite the disease, which at 
times seems to occur in epidemic form. Most cases are 
seen in the latter part of Winter or Spring. 

The disease is thought to be caused by a germ because 
it begins with symptoms generally connected with the 
acute infectious diseases, as sore throat, malaise, head- 
ache, etc.; because there is a tendency to relapse; be- 
cause it occurs in epidemic form; because the symptoms 
and complications resemble those of bacterial diseases; 
and, finally, because it is usually accompanied by anemia. 

Reasons for believing it not to be due to germs are: 
no germ has been found; it has a hereditary tendency; 
it recurs in the same individual. 

Another theory ascribes its cause to a toxemia due 
to the presence of acetic acid or uric acid in the blood, 
and another holds it to be of nervous origin. 

Allies of rheumatism are chorea, follicular tonsillitis, 
and torticollis. 

1 88 



ACUTE ARTICULAR RHEUMATISM 189 

Symptoms. — -The disease may be ushered in gradu- 
ally by a few days of discomfort, malaise, loss of 
appetite, and other indefinite symptoms; or it may 
commence suddenly with a chill or chilliness. Sore 
throat and tonsillitis are frequent forerunners of acute 
rheumatism. They occur in from thirty to sixty per 
cent, of cases. In the course of a few days the joint 
symptoms begin to make their appearance. The 
joints which are attacked become very painful, and 
redness and swelling of the affected joints soon appear. 
The joints become exquisitely tender and even the 
weight of light bedclothing can not be borne. The 
tissues about the joints may be greatly swollen, or even 
the whole limb. 

The pain is excruciating and is produced by the 
slightest movements. One characteristic is the rapid 
migration of the joint symptoms. 

The temperature varies from io2°F. to io3°F., but 
may reach a very great height. Hyperpyrexia is not 
uncommon in acute rheumatic fever. The pulse be- 
comes rapid and may be irregular. 

A very characteristic symptom is the profuse, drench- 
ing sweats. The perspiration is acid and has a sour, 
foul odor. The temperature falls after the sweat. 
Miliaria and sudamina are of frequent occurrence. 

The tongue is coated, the bowels are constipated, and 
the appetite is lost. 

The urine becomes very acid, scanty in amount, dark 
in color, high in specific gravity, and contains an abun- 
dance of urates. The person becomes very anemic due 
to an alteration of the blood by the toxic substance. 

Complications. — Endocarditis, pericarditis, and myo- 
carditis are the principal cardiac complications. Of 



190 FEVER NURSING 

these endocarditis is the most frequent and most seri- 
ous. The mitral valve is usually affected. Small vege- 
tations form on the line of closure of the valves. In 
these vegetations germs have been found. Rise in 
temperature, palpitation of the heart, and change in 
the pulse character will denote the onset of this 
complication. 

Pericarditis may be of the dry or moist form. The 
moist form may be serous, purulent, or hemorrhagic. 
It may develop at any stage of the disease. Heart 
complications are known to have developed before the 
joint symptoms have appeared. 

Pleurisy with effusion of one or both sides may occur. 

Other complications are hyperpyrexia, meningitis, 
delirium, convulsions, coma, chorea, pneumonia, ne- 
phritis, eyrthema nodosa, purpura, and hematuria. 

Course. — In mild cases the joint symptoms dis- 
appear in two or three days, the temperature falls but 
the sweats may continue. Relapses are frequent and 
point to an infectious nature. Hyperpyrexia, menin- 
gitis, and heart complications are unfavorable. Death 
may occur suddenly, due to myocarditis. The disease 
may become subacute or chronic. 

Care and Management. — The room in which the 
patient is confined should be airy and well ventilated. 
Absence of draughts of air is very essential. The tem- 
perature of the room should be kept constantly at or 
near 68° F. 

The patient should wear a light flannel gown and 
undershirt, as flannel absorbs moisture very easily 
and will protect the patient from the cold. The patient 
for the same reasons should sleep between blankets and 
not sheets. 



ACUTE ARTICULAR RHEUMATISM 191 

The diet is to be liquid. Milk will form the bulk of 
the diet during the acute stage. If whole or undiluted 
milk does not agree with the patient, it may be diluted 
with Vichy, barley water, limewater, or even plain 
water. Buttermilk, skim milk, albumin water may 
form part of the diet. No meat or meat preparations 
should be given during the course of the disease. 

Thirst is as a rule constant and great. It may be 
relieved by providing water freely. Lemonade, oat- 
meal water, and seltzer water are allowable. 

The basis of all medication is salicylic acid or some 
of its salts, the salicylates. These preparations are 
more or less disagreeable to take and may upset the 
stomach. The patient will consider it a favor if these 
medicines be administered in an agreeable form. The 
salicylates may be given dissolved in milk, or dissolved 
in milk and peptonized, forming a curd or sort of a 
salicylized junket. Another palatable form is prepared 
by dissolving the drug in water and adding some 
glycerine. 

Local Measures. — 'These are without number. Of 
all applications there are three or four which I have 
found of special service. First and foremost the ice- 
bag. Even the mentioning of this to the patient will 
make him shudder. He will even rebel against it. It 
may require a little diplomacy on the part of the nurse 
to carry out this method, but after the first application 
the patient does not object as the results are very 
gratifying. Do not place the bag next to the skin but 
have a piece of woolen cloth intervene. 

Second, an application consisting of one dram of 
salicylic acid, one ounce of oil of wintergreen, and up 
to eight ounces of cotton-seed oil. 



192 FEVER NURSING 

Third, a twenty or fifty per cent, ointment of ichthyol, 
the base of which is lanolin. 

Fourth, a preparation consisting of one part of 
guaiacol and three parts of glycerine. 

Other external applications are methyl salicylate; 
lead and opium wash; Fuller's lotion (consisting of 
sodium carbonate, one ounce; tincture opium, one 
ounce; glycerine, three ounces; water, twelve ounces); 
chloroform liniment; tincture of iodine; sulphur pow- 
der; and vinegar. 

Fever is treated the same as in other febrile dis- 
eases, by the application of cold in the form of sponges, 
packs, and baths. 

Delirium is quieted by hydrotherapeutic measures. 
It is important to remember that delirium may result 
from the exhibition of salicylic compounds. A patient 
of the author's, seen for the first time at the end of 
the first week of the disease, had had no delirium. 
Within twelve hours after beginning salicylates the 
man became very delirious. The delirium ceased with 
the withdrawal of the salicylates but returned when 
the medication was again instituted. 

Careful attention must be paid to the heart as this 
organ is often profoundly affected in rheumatism. 

Convalescence. — The patient is not to get out of 
bed until the temperature has been normal for a week, 
and not even then if any heart complications are pres- 
ent. The diet is to be gradually increased until full 
diet is resumed. Meats, especially the red ones, are 
to be but sparingly given. Special care must be taken 
to avoid exposure to cold and wet. Light massage of 
the joints and muscles is beneficial. 



CHAPTER XXII 
MALARIAL FEVER 

Etiology. — The exciting cause of malarial fever 
is probably the plasmodium of Laveran. This organ- 
ism is not a bacterium but one of the protozoa. 

Predisposing Causes. — The disease is especially ac- 
tive in the temperate and tropical zones; in swampy 
and marshy regions; along rivers, especially those 
streams which overflow their banks; in new agricul- 
tural districts and near large excavations. 

Poor surface drainage is one of the main factors in 
predisposing the disease. The most cases appear in 
Spring and Summer, especially after a prolonged dry 
season. The winds seem to carry the disease from 
place to place. 

Symptoms. — The disease may be preceded by pro- 
dromal symptoms as malaise, loss of appetite, suboc- 
cipital headache, feeling of uneasiness in the epigas- 
trium, nausea, and a desire to yawn. 

The paroxysm is divided into three stages: namely, 
the cold stage, the hot stage, and the stage of sweat- 
ing. 

Cold Stage. — There is general chilliness, the patient 
shivers, the face becomes pinched, the lips blue, and 
a pronounced chill occurs, lasting from five to sixty 
minutes or more. The surface of the body is pale 
and cold but the temperature is raised (io3°F. to 
io6°F.). The pulse is rapid, small, and hard. The 
urine is increased in amount. 
13 193 



194 



FEVER NURSING 



Hot Stage. — This stage develops in five to fifteen 
minutes after the former. Instead of chilliness or chills 
there is a feeling of warmth, the formerly pale skin be- 



O'.i 
















fii-Lffi 
ICS 


4 8 12 4- 8 12 


4- 8 12 4- 8 12 


4 8 12 4 

| | | 


8 12 


4- 


S 


12 


4 8 12 


4 8 12 4 8 12 

_| | 1 1 -4— 


4 


8 


12 4 8 12 


!08 


107 

106 


i ; : , = 


-p- | | = 






















IC7 
106 
105 
104 


105 | '' : 1 j I 
104 \ 1 A i = 






















I02{ : f 1 j 

101 1 i /i — \— — 




















103 
101 


I0O /: 1 
99 ! ! 'f \ \ 




















100 
99 
93 
97 
























97 n i i ; 















































Fig. is. — Temperature chart of intermittent malaria (tertian). 



DAY 
















h:j? 


4 8 12 4 8 12 


4 8 12 4 8 12 


4 8 12 4 8 12 


4 8 12 4 8 12 


4 8 12 4 8 12 


4 8 12 4 8 12 




108 




: i 




































;09 


107 

!0r- 








































10.' 
106 
105 


105 


























104 
105 

:: 

101 
100 
99 
98 

q? 


/ 1 1 
































103 
\0l 




























101 

100 
99 
98 
q? 










































11,, 









































Fig. i6. — Temperature chart of intermittent malaria (quotidian). 

comes flushed, the face congested. The pulse hitherto 
small and hard is now full and bounding. The headache 
is intense and throbbing. The urine becomes scanty in 



MALARIAL FEVER 



195 



amount. The patient is very thirsty. The temperature 
varies but a fraction from that in the cold stage. De- 



oay| 














Ms|4 8 12 4 S 12 


4 8 12 4- 8 12 


4 8 12 4 8 12 


4 8 12 4 8 12 


4 8 12 4 8 12 


4 8 12 4 8 12 




108 1 J 11 1 1 
























































108 


I07| | } | | ! 


























































107 
106 
105 
104 
103 


IQbj | | | 1 
































105 J [ 




























I04-| - 

I03| 1 


























































102) 1 mm 












































102 
101 
100 
99 

98 


100 'i\ \ 












































93 '/ | ! i\ 

98U|*'| | jV 
























































1 — J — | — 














~^~ 














































97 


1 — 1 — — 


— 1 — 

























































Fig. 17. — Temperature chart of intermittent malaria (quartan). 



"DAY 










1 




H0US5 
108 


4 8 12 4 8 12 


4 8 12 


4 


8 


12 


4 8 


12 


4 8 


12 


4 


8 


(2 


4 


8 


12 


4 


8 12 


4 


8 


12 


4 


3 


12 


4 


8 


12 


108 


107 
!06 
105 
104 
103 
I0Z 
10! 
100 
99 
9ft 






















































107 
106 
105 
















































103 
102 

101 
100 
99 
9ft 






























































































































































97 
















— 1— 






































97 



Fig. 18. — Temperature chart of remittent malaria. 

lirium is common. This stage may last from thirty min- 
utes to five hours. 

Sweating Stage. — The pains and anxiety of the former 
stages are relieved by the advent of this stage. Sweating 



ig6 FEVER NURSING 

usually begins on the forehead and extends over the 
whole body. The pain and feverishness are decreased 
and complete relief is ushered in by refreshing sleep. 
This stage lasts from one to three hours. 

The whole paroxysm lasts from two to fifteen hours. 
Throughout the paroxysm the spleen is enlarged and 
tender and the viscera are congested. Herpes of the 
lips are common in malaria, the tongue is coated, con- 
stipation or diarrhea may exist. 

Fever. — The temperature rises in the cold stage and 
continues high until the sweating begins, when it falls. 
The temperature rises with each paroxysm and the fre- 
quency depends on the character of the infection. In 
the tertian type the paroxysms occur every other day. 
In the quotidian they occur daily. In the quartan on 
the fourth day. There may be a double infection of the 
same type or mixed infections of the various types. 

Varieties. — There are four principal forms of malaria: 
intermittent, remittent, pernicious, cachectic. The in- 
termittent form is described above. 

Remittent form, also known as bilious remittent fever, 
estivo-autumnal fever, and irregular malaria. 

Symptoms. — Malaise and chilliness. The fever is ir- 
regular, rises gradually, and usually drops by lysis. 
The paroxysm is not well defined. The face is flushed, 
the conjunctivae are injected. Nausea, vomiting, and 
epigastric pain are very common. Jaundice occurs in 
many cases. Delirium is frequent. The general course 
resembles typhoid fever to a great degree. 

Pernicious Malaria. — This is a very grave form. 
There are three types, the algid, the comatose, and the 
hemorrhagic forms. 

The Algid Form. — As the name would indicate, this 



MALARIAL FEVER 1 97 

form is characterized by the coldness and low tempera- 
ture. Vomiting is frequent, prostration is very great, 
the pulse is rapid, feeble and small; the temperature 
may be subnormal; the urine is suppressed, very dark 
jaundice is characteristic, and collapse may follow an 
exhausting diarrhea. 

The Comatose Form. — The chill is of short duration 
or absent. The skin is hot, the temperature is high. 
The nervous symptoms are marked. The delirium is 
followed in many cases by coma and death, or the un- 
consciousness may last ten or twelve hours and then 
cease. A second paroxysm is generally fatal. 

The Hemorrhagic Form. — This form is characterized 
by the tendency to hemorrhage from the mucous mem- 
branes and the kidneys. There are no febrile paroxysms, 
hematuria is common, jaundice is not as marked as in 
the algid form. 

Malarial Cachexia. — This is a chronic malarial in- 
toxication, caused by a continued progress of a simple 
form. It is characterized by its great anemia and 
chronic enlargement of the spleen. There is a tendency 
to bleeding from the mucous membranes, uterus, and 
kidneys. The skin is sallow. Headaches are common 
and severe. 

Prognosis. — Always favorable in the simple inter- 
mittent form, although chronic malarial cachexia may 
follow. Favorable in the remittent form. Always grave 
in the pernicious forms, especially in the algid type. 

Care and Management. — Malaria is transmitted 
by means of the mosquito, which acts as the interme- 
diary host. Thus it will be seen that if a region infected 
with malaria is freed of mosquitoes, the disease will 
gradually disappear. The breeding places of the mos- 



198 FEVER NURSING 

quito are stagnant pools and slow flowing waters. The 
water found in road ditches, in old cans, in rain barrels, 
in tree stumps, in the angles of the boughs and the tree 
trunk, along the sides of slow-flowing creeks, forms an 
excellent field for the development of the larvae of the 
mosquito. 

All road ditches and puddles should be filled with 
earth to prevent the water from collecting. Rain barrels 
should be covered with very fine meshed netting. Holes 
in trees should be packed. Pools of large size should be 
treated with kerosene oil. This forms a film on the sur- 
face of the water, preventing the embryo mosquito from 
getting fresh air and therefore causing its death. 

Small fish in a stream, pond, or fountain will eat the 
larvae and thus prevent to a great extent the develop- 
ment of the mosquito in these waters. 

The house should be protected from the invasion of 
the mosquito by means of screens. Bed canopies are 
also useful barriers. 

General Management. — In the intermittent form of 
malaria the patient must be confined to bed during the 
paroxysm, but may be allowed to leave the bed between 
the attacks if he feel strong enough and object to re- 
maining in bed. In the remittent and pernicious forms 
absolute rest in bed is a necessity. 

The diet as in other febrile diseases is to consist mainly 
of milk and liquid foods. 

Of all drugs used in the treatment of this disease 
quinine holds the first place. This drug acts directly on 
the cause of the disease, the plasmodia, and destroys 
their vitality. The object of the treatment is to prevent 
future paroxysms and not to stop the paroxysm which 
is in progress, as this can not be done. There are two 



MALARIAL FEVER 1 99 

methods of giving quinine, in one massive daily dose; 
and in small divided doses with a larger dose before 
the expected paroxysm. By the former method the 
toxic effects of the drug may be excited. 

As quinine is slow in absorption, the last dose should 
be given several hours before the oncoming attack. 

If a purge, as calomel, be given an hour before the 
administration of the quinine, this latter drug will act 
much more quickly and better. 

In some susceptible individuals the toxic effects of 
quinine, known as cinchonism, come on quickly and even 
after a comparatively small dose. The signs of this 
condition are ringing in the ears, vertigo or dizziness, 
nausea, vomiting, fullness of the head, impaired vision, 
and at times deafness. 

During the cold stage the patient may be made much 
more comfortable by covering him well with blankets, 
placing hot-water bottles to the extremities, and giving 
hot drinks. If the chill be very severe, inhalations of 
chloroform or amyl nitrite will be of service. Atropine 
by hypodermic is useful. 

The hot stage is best treated by cool sponges or rubs. 
An ice-bag to the head is very grateful to the patient. 

In the sweating stage the patient is made more com- 
fortable by using such coverings as will easily absorb 
the moisture caused by perspiring. 

The remittent form is managed on the same plan, more 
or less, as in typhoid fever. Absolute rest in bed, liquid 
diet, attention to the bowels and temperature. In case 
of tympanites, the turpentine stupes will be found 
useful. 

Vomiting, which is very frequently present in this 
form, must receive especial attention. Small pieces of 



200 FEVER NURSING 

ice by the mouth and a mustard paste to the epigastrium 
are of benefit. 

The pernicious form as has been stated is very grave 
and needs vigorous treatment. The purpose of prime 
importance is the prevention of a second paroxysm. 
Quinine is given in enormous doses. Stimulants are to be 
freely administered. 

In the algid type the external application of heat is of 
prime importance. 



CHAPTER XXIII 
ERYSIPELAS 

Definition. — An acute, infectious fever characterized 
by an acute inflammation of the skin and general symp- 
toms of toxemia. 

Etiology. — The exciting cause of erysipelas is the strep- 
tococcus erysipelatis which is said to be identical with 
the streptococcus pyogenes. 

The germ gains entrance through some break in the 
continuity of the cutaneous or mucous surfaces. In 
cases of facial erysipelas the bacterium usually finds a 
portal of entrance in the nasal passages. 

Certain individuals seem particularly predisposed. 
Some women have recurrent attacks at the menstrual 
periods. Relapses and recurrences are liable. 

Symptoms. — Constitutional. Rigors or chills generally 
usher in the attack. Several days of malaise, frontal 
headache, and gastric disorders may precede the general 
signs. In twenty-four hours the local lesion is generally 
manifest. 

The temperature rapidly becomes high (io4°F.), the 
pulse rapid, prostration is more or less prominent. The 
tongue is dry. The urine is scant in amount, dark in 
color, of a high specific gravity, and contains albumen. 
The bowels are usually constipated. Delirium is not 
uncommon. 

Local. — A small inflamed area of a dusky red color is 
first seen. The local lesion is painful and tender and a 



202 FEVER NURSING 

sensation of tension is frequent. The area of inflam- 
mation has a prominent well-defined margin. There is 
more or less swelling which pits on pressure. The lesion 
spreads from the periphery while healing in the center. 
Migration is rapid and a great portion of the body may 
become affected. 

In facial erysipelas the eyelids and surrounding tis- 
sues may become greatly swollen, and the eyes closed. 
The whole face is sometimes swollen beyond recognition. 
Blebs or large blisters are of frequent occurrence on the 
face, eyelids, and forehead. In four or five days the 
redness begins to fade and the swelling to decrease, and 
unless recrudescence occur the process is at an end. 

Complications. — Pneumonia, pleurisy, pericarditis, and 
endocarditis are not uncommon. Nephritis is a very 
serious complication, as also is septicemia. 

Prognosis. — A simple case usually results in recovery 
in about two weeks. The prognosis is less favorable 
in those individuals suffering from other diseases, as 
nephritis, and in alcoholics and during the puerperal 
state. 

Chronic swelling of the parts and eczema are common 
sequelae. 

Care and Management. — This disease is of a general 
character and not simply a local disease of the skin, as it 
was formerly thought to be. 

Complete isolation of the patient is the first requisite. 
A very mild case of facial erysipelas may excite in a 
susceptible individual a most severe and fulminating 
form of the disease. Young children are especially 
likely to contract the disease, as are also women in the 
parturient stage. Dr. Goodell believed there is a rela- 
tionship between puerperal sepsis and erysipelas. 



ERYSIPELAS 203 

The nurse or attendants should not come in contact 
with anyone suffering with an ulcer or an open wound 
of any kind, as these persons are very easily infected 
with erysipelas. 

A nurse who has been attending a patient ill with 
erysipelas should under no circumstances undertake the 
care of a parturient woman until she (the nurse) is ab- 
solutely free from the danger of carrying infection. It 
will be safe to do pure medical nursing before entering 
surgical or obstetric service. 

Rest in bed is necessary in the more severe cases, as 
the disease is very depressing. In the mild cases the 
patient may be up and around for part of the day. 

The diet is of great importance and should be concen- 
trated and very nourishing, as milk, gruels, eggs, etc. 
First because the disease is very depressing and pros- 
trating, and secondly because recovery depends on the 
vitality of the patient, which can be kept in a good state 
only by providing the most nutritious foods. 

The bowels should be kept open by saline laxatives 
and enemata. 

Headache, which is often very trying, is relieved by 
the application of an ice-bag to the head. 

Fever, if high, is lowered by means of sponges, packs, 
and baths. 

Sleeplessness is overcome by a glass of hot milk, to- 
gether with a hot foot bath and an ice-bag to the 
head. 

The kidneys, which are liable to be affected in this 
disease, should be kept active by giving the patient 
plenty of drinking water. 

The heart should be carefully watched. 

Of internal medicines the tincture of chlorid of iron, 



204 FEVER NURSING 

and some salt of quinine are most frequently given. 
These are simply mentioned in passing. 

Antistreptococcic serum is much praised by eminent 
authorities. 

We now come to local measures. These are manifold. 
Ichthyol probably holds the first place. Of all local 
applicants I have found it the most beneficial. It may 
be applied in one of several ways: as an ointment of 
twenty-five per cent, strength, or dissolved in water or 
glycerine (i to 4). 

A most excellent method is by combining it with 
collodion and painting it over the lesions. This method 
causes exclusion of air, which is very important, and also 
keeps the medicament in contact with the lesion. 

One important point to be remembered in the use of 
ichthyol is that it should be freely applied. 

Other applicants are resorcin which may be used alone 
or combined with ichthyol; solution of lead acetate; 
carbolic acid, 1 to 20; bichlorid of mercury, 1 to 1000; 
tincture of iodine; solution of boric acid; silver nitrate 
in a solution of 1 to 3. 

If the lesion be on one of the extremities, adhesive 
straps applied around the limb above and below the site 
are said to prevent its extension. 

If the case be one of facial erysipelas, attention should 
be given to the nasal and pharyngeal cavities and to 
the mouth. These should be cleansed by antiseptic 
solutions, as sprays, douches, and gargles. A 1 to 
8 solution of hydrogen peroxid is very good. 

All dressings should be burned as soon as removed. 

The nurse should scrub her hands thoroughly and im- 
merse them in a 1 to 1000 solution of bichlorid of mercury 
after each dressing and before eating her meals. 



ERYSIPELAS 205 

The patient should have separate towels, washcloths, 
and eating utensils. 

After convalescence cheap articles of clothing should 
be burned and other pieces may be disinfected with the 
room, as described under Scarlet Fever. 



CHAPTER XXIV 
SEPTICEMIA, TOXEMIA, AND PYEMIA 

Definitions. — These terms are being constantly con- 
fused and interchanged. Each is a distinct condition 
and it is important that they be thoroughly understood. 
I will endeavor to define each in simple and concise form. 

Toxemia is a morbid condition characterized by the 
presence of toxines in the blood. An example is diph- 
theria. In this disease the local lesion as a rule is on 
one of the mucous membranes of the upper respiratory 
tract. The germs themselves rarely leave the local site, 
but the toxines or poisonous products which the bacteria 
form are absorbed and enter the blood; then they are 
carried throughout the body and give rise to general 
constitutional symptoms. 

Septicemia is a morbid condition characterized by 
the presence of bacteria and their toxines in the blood. 
Typhoid fever is an example of a septicemic condition. 
Here we find the typhoid bacillus in the circulation. 

Pyemia is a morbid condition characterized by the 
presence of pus-producing germs in the blood, together 
with the formation of secondary purulent deposits or 
metastatic abscesses. 

Sapremia is a morbid condition characterized by the 
presence in the blood of the products of decay or putre- 
faction. For example, after a partial ectopic rupture 
a clot of blood will be found in the pelvis. This may 
soon be invaded by micro-organisms and decompose. 
The products when absorbed give rise to toxic symptoms. 

206 



SEPTICEMIA, TOXEMIA, AND PYEMIA 207 

All the conditions described above are referred to by 
the laity as blood poisonings, which in reality they are. 

Etiology. — These conditions may be caused by any 
bacterium. Toxemias usually occur in the acute in- 
fectious diseases. Pyemia may follow any operation, 
being due to infection by pus-producing organisms, as 
the staphylococci and streptococci. Sapremia is fre- 
quent in incomplete abortion, in retention of the pla- 
centa in whole or in part, or of parts of the membranes; 
also in conditions accompanied by extensive sloughs. 

Symptoms. — Toxemia. The general symptoms of 
toxemia are chill or chilly sensations, fever, headache, 
malaise, loss of appetite, restlessness, prostration, rapid 
pulse, and in pronounced cases delirium, coma, nausea, 
vomiting, and diarrhea. 

Septicemia. — The symptoms are similar to those of 
toxemia but are much more severe. The chill may be 
pronounced, the fever is at first moderate but soon 
becomes high and runs a very irregular course with 
daily remissions or intermissions; the pulse becomes 
very rapid and feeble. Nausea and vomiting are not 
infrequent. Nervous symptoms are common: delirium, 
apathy, and convulsions (in the young). A very char- 
acteristic occurrence is the enlargement of the spleen 
and the lymph glands. 

Pyemia. — This condition in most instances is ushered 
in by a pronounced chill. The chills recur frequently, 
in some cases daily and more or less often. With the 
chill there is a rapid and high rise of temperature. 
These paroxysms recur. The temperature may reach 
io3°F. to i05°F. and is followed by a more or less pro- 
fuse sweat, after which the temperature is again low. 
These phenomena resemble very much those of malaria. 



208 



FEVER NURSING 



The general symptoms are general malaise, headache, 
loss of appetite, nausea, and vomiting. As the disease 
progresses prostration becomes very marked, anemia 
develops, the skin takes on a sallow hue, diarrhea may 
be exhausting, and the patient may develop a low ty- 
phoid condition with delirium, subsultus tendinum, etc. 

Abscesses may form in any part of the body: in the 
joints, subcutaneous tissues, or in the viscera. 




Fig. 19. — Temperature chart of pyemia. 



Care and Management. — The outcome of these dis- 
eases depends largely on the nursing. Their course is 
so irregular and varied, their character is so general 
that the treatment consists principally of supportive and 
expectant measures. 

Support of the strength of the patient is the most 
important requisite. These diseases run their course 
and recovery depends on the vitality of the patient. 

The patient's vigor is conserved best by absolute 
rest in bed and a most nourishing diet. Milk will form 
the basis of the diet and is to be supplemented with 



SEPTICEMIA, TOXEMIA, AND PYEMIA 2O0, 

gruels, eggs in soft form, albumin water, broths, pre- 
digested forms of beef, etc. 

Symptoms should be alleviated as they arise. 

Fever, if it become excessive, is treated by the appli- 
cation of tepid or cool water in the form of sponges, 
packs or baths. 

Delirium, which may occur, is also quieted by these 
same means. 

Vomiting may be so severe that no food or medicine 
can be retained in the stomach. In these instances 
medicine must be given hypodermically if possible or 
by rectum. Nutritive enemata should be instituted. 
Oftentimes a mustard paste applied to the epigastrium 
will stop the vomiting. Washing out the stomach is 
of good service in selected cases. 

Sweating, which is common, especially in pyemic 
cases may be lessened by bathing the body with alcohol, 
or a combination of alum one ounce, alcohol one-half 
ounce, and water two pints. 

Stimulation is of frequent necessity. For general 
stimulation of the heart digitalis and strychnine by 
mouth are of greatest value. When rapid stimulation 
is necessary hypodermic injections of strychnine, ether, 
or spirits fermenti are indicated; or give by mouth 
dram doses of aromatic spirits of ammonia or compound 
spirits of ether. The use of camphor dissolved in sterile 
olive oil is an excellent stimulant. It should be given 
by hypodermic and in one-grain doses. 

Elimination of the toxines is of vital importance and 
should be encouraged by one or all of the following 
methods. 

By the Bowels. — The bowels should be kept open 
by means of calomel, or better, by saline cathartics, as 
14 



2IO FEVER NURSING 

magnesium sulphate (Epsom salts), or sodium and 
potassium tartrate. 

In some cases of pyemia a colliquative diarrhea oc- 
curs. This should not be checked at once as it is one 
of nature's ways of expelling toxines. A large quantity 
of the toxines are excreted into the bowels; therefore, 
by emptying the intestines we get rid of a large amount 
of toxines. 

Washing out the colon is of excellent service. I 
have found a most admirable method in the use of the 
Kemp double rectal irrigating tube, which allows a cir- 
culation of water to take place in the rectum and colon. 
The inflow tube is connected with the source of water, 
as a fountain bag or an irrigating jar; the outflow 
tube is connected with a large tube by means of rubber 
tubing. Normal saline solution is used in large quan- 
tities. In one case I used as much as fifty gallons of 
the solution. 

The temperature of the solution used in colonic irri- 
gation should be of such a degree that when it reaches 
the colon it is not above Q9°F. If a long tube be used 
on the fountain bag, the temperature of the solution 
may be io4°F. If a short tube be used, then ioo°F. 
or ioi°F. is enough. If the temperature of solutions, 
when large quantities are used, be too high, there is a 
liability of producing heat stroke, or of causing ex- 
cessive fever in the patient. 

By the Skin. — 'Sweating is promoted by hot drinks, 
by wrapping the patient in hot dry or wet blankets, or 
by introducing heat under the bedclothing by means 
of a hot-air apparatus. Hypodermoclysis of normal 
saline solution is very useful. 

By the Kidneys. — Give the patient plenty of water 



SEPTICEMIA, TOXEMIA, AND PYEMIA 211 

to drink. Encourage the flow of urine with the spirits 
of sweet niter. Hypodermoclysis of normal saline so- 
lution is of especial value in eliminating the toxines by 
the urine. They should be given as regularly as any 
medicine. One case of severe sepsis under my care 
was saved by the systematic giving of normal salt solu- 
tion under the skin. 

Use of Antitoxin. — Marmorek in 1895 announced 
the discovery of an antistreptococcic serum and also re- 
ported its successful use in many septic cases. Whether 
it be of any real value in general infections is yet to 
be ascertained. It is given in the same way as the 
diphtheria antitoxin, in doses of ten cubic centimeters. 

The use of organic silver salts I think will, in the 
future, partially solve the treatment of general infec- 
tious processes. 



PART III 

ADDENDA 

CHAPTER XXV 
ANTITOXINS AND BACTERIAL VACCINES 

Antitoxins 

One of the greatest, if not the greatest advance in 
medical science during the last decade, was the pro- 
duction of substances which counteract the destruc- 
tiveness of bacterial poisons. 

Closely connected with the subject of antitoxins is 
that of immunity. 

Immunity may be complete or partial, natural or 
acquired, temporary or permanent. 

Natural immunity for the various infectious diseases 
is enjoyed by not a small number of persons. 

Acquired immunity is obtained in various ways: By 
the injection of antitoxins; by modified virus and vac- 
cines, as in smallpox; by the gradual injections of tox- 
ines; by the gradual injection of virulent cultures; by 
a previous attack of the disease. 

All the above means bring about the same ultimate 
result, a stimulation of the body cells to form certain 
antagonistic bodies or antitoxins. 

When bacteria gain entrance to the human body, 
they begin to multiply in number and form certain 
poisonous substances known as toxines, and these circu- 

213 



214 FEVER NURSING 

late in the blood and cause general "blood poisoning" 
or toxemia. It is this generalization that causes the 
seriousness of the disease. The germs themselves, 
as a rule, remain in a local place. In typhoid fever 
the germs find their resting place in the coats of the 
bowels; in pneumonia, in the lungs; in diphtheria, on 
the mucous membranes of the larynx, pharynx, or 
nose. If the germs also enter the circulation and are 
scattered far and wide, the condition is known as 
septicemia. If the germs after being scattered about 
the body form abscesses, the condition is called pyemia 
and the abscesses are designated metastatic abscesses. 
While mentioning the different forms of "blood poi- 
soning" I will call attention to a fourth form, known 
as sapremia. This is caused by a circulation in the 
blood of putrefactive material. A good example is 
found after labor and results from a retention of all or 
part of the placenta. The part that remains in the uterus 
will soon decompose and this material, when ab- 
sorbed, will cause a certain septic condition known as 
sapremia. 

The toxines mentioned above, when circulating in the 
blood, act upon the cells of the body and cause the 
appearance of symptoms characteristic of the disease. 
The body cells on the other hand, as soon as harassed 
by these toxines are stimulated to resistance, which is 
effected by the formation of bodies which antagonize 
the toxines, and are known as antitoxins. 

If the toxines be weak or small in quantity, the body 
cells may overcome their deleterious action, and the 
individual survives. If the toxines be very virulent and 
the resistance of the person be low, then the bacteria 
are the victors and the individual perishes. 



ANTITOXINS AND BACTERIAL VACCINES 215 

If the toxines be virulent and the resistance of the 
person be great, the battle is more evenly balanced 
and the victory may be won by either side. First the 
laurels sway to one side and then to the other. It is 
in this type where the reinforcement sent by the phy- 
sician will aid the patient in conquering. 

As said above when toxines enter the body the cells 
of the body at once begin to produce defensive agents 
in the form of antitoxins. Before discussing the pro- 
duction of antitoxins a few definitions are necessary. 

A toxine unit is ten times the amount of toxine re- 
quired to kill in twenty-four hours, a guinea-pig weigh- 
ing 250 grams. 

An antitoxin unit is ten times the amount of anti- 
toxin required to neutralize one toxine unit. 

Production of Antitoxin. — In discussing the pro- 
duction of antitoxins I will follow the procedure used 
in producing diphtheria antitoxin. 

A culture is made by planting live diphtheria bacilli 
in sterile bouillon and this is placed in a warm room 
to grow from four to seven days. The result is what 
is called a virulent culture. This culture is then at- 
tenuated by adding to it carbolic acid until it becomes 
five-tenth per cent, solution. It is then filtered through 
stone ware, which removes the germs and foreign matter 
and a clear solution results containing the toxines. This 
toxine solution is tested as to its strength by the inocu- 
lation of guinea-pigs. The strength having been de- 
termined, it is ready for use. 

For the production of antitoxin the horse is used 
because of the large amount of blood it contains, be- 
cause of its more or less immunity, and because of its 
easy management. 



2l6 FEVER NURSING 

Into the muscles of the horse's neck is injected ten 
to twenty toxine units of toxine. In twenty-four to 
forty-eight hours the area will become red, swollen, and 
hot. The temperature becomes high and signs of de- 
pression ensue. After two or three days these symp- 
toms disappear when another and larger dose of toxine 
is injected, and so on until enormous doses of this toxine 
are given. At the end of one to three months the 
serum of the horse's blood will be rich in antitoxin. 

Test bleedings are made from time to time to deter- 
mine the amount of antitoxin present and when suffi- 
cient is present the final bleedings are made every few 
days until twenty or more liters of blood are removed 
from the horse. About one-half of the bleeding will 
be serum which is collected in sterile vessels and is 
prepared to be sold as antitoxin. 

The horse, after a short rest, is again injected with 
toxines. 

If when the toxines are injected, there be antitoxin 
injected at the same time, the dose of toxine may be 
greater and the horse is immunized very rapidly, each 
successive injection containing less antitoxin and more 
toxine. 

Varieties of Antitoxins. — Of all antitoxins, great- 
est success has followed the use of diphtheria antitoxin. 
The antitoxin should be administered as early as pos- 
sible and in large, frequently repeated doses. Anti- 
toxin itself is not poisonous but the serum may cause 
disturbing symptoms. 

The average curative dose is 3000 units, and for 
immunizing purposes at least 500 units should be 
given. The immunity is temporary, lasting from four 
to six weeks (H. Biggs). 



ANTITOXINS AND BACTERIAL VACCINES 217 

Other antitoxins which have been produced with 
greater or less success are those against the streptococ- 
cus, tetanus bacillus, typhoid bacillus, bacillus of bu- 
bonic plague, yellow fever, pneumonia, cholera, etc. 

Bacterial Vaccines 

Dr. Wright, of London, has been foremost in the 
introduction into medicine of the use of bacterial vac- 
cines. These vaccines consist of killed cultures of 
bacteria and, when injected into man, aid the body to 
overcome the action of the specific infection by stimu- 
lating the cells to increased protective energy. The 
immunity conferred by the use of vaccines differs from 
that of antitoxins in that the latter is passive, whereas 
the former is active. 

Bacterial vaccines are killed disease germs held in 
suspension in a sterile physiological salt solution 
to which has been added a small amount of some anti- 
septic for the purpose of preservation. These vaccines 
are standardized so that a given quantity contains a 
known number of killed germs. 

The action of bacterial vaccines when injected into the 
body is that of establishing an active immunity toward 
that particular germ, much as is naturally done in our 
bodies. The introduction of these dead germs stimulates 
the body cells and fluids to create or form certain anti- 
bodies, which aid in the destruction of the live disease 
germs which menace the person. Opsonins are also 
formed. The leucocytes or white blood corpuscles will 
and do absorb and destroy disease germs. When the 
germs are first acted upon by the opsonins they are more 
readily devoured and obliterated by the leucocytes. 



2l8 FEVER NURSING 

The bacterial vaccines are administered under the 
skin in the same way and with the same aseptic pre- 
cautions as a regular drug hypodermic injection. 

These vaccines have a twofold use: first, as curative 
agents in combating certain diseased conditions and 
secondly, as preventive agents. The most notable 
example of the latter class is the typhoid vaccine. The 
prevention of typhoid fever by the use of a bacterial 
vaccine has been one of the most illustrious advances of 
biological medicine in late years. The results are re- 
markably exact, as attested by its use in the great armies 
of the world. 

Major F. F. Russell of the U. S. Army, in a report on 
antityphoid vaccination, states: "One can best judge of 
the combined effects of vaccination and sanitation by 
comparing the camp located at San Antonio, Texas, with 
the one located at Jacksonville, Florida, in 1898. At 
Jacksonville there were assembled 10,759 men, among 
whom there were 1729 undoubted cases of typhoid, and 
including those in which a diagnosis of typhoid was prob- 
able there were 2673 cases, with 248 deaths. This camp 
lasted approximately as long as the camp at San Antonio 
in 191 1 ; both camps were situated in about the same 
latitude and each had artesian well water of excellent 
quality, yet in 1898 there were over 2500 cases of ty- 
phoid fever, with 248 deaths, and in 191 1 only 2 cases, 
with no fatalities. We know that the immunity was not 
due to lack of exposure, since there were reported to the 
health office 49 cases of typhoid fever, with 19 deaths, 
among the civil population of the city of San Antonio 
during the period of encampment." 

Every person who in any way is liable to come in 
contact with typhoid infection should be immunized by 



ANTITOXINS AND BACTERIAL VACCINES 219 

the use of typhoid vaccine. Nurses, physicians, stu- 
dents in colleges and boarding schools, traveling salesmen, 
tourists, summer vacationists will derive great protec- 
tion from its employment. 

Among other bacterial vaccines of known value are the 
acne-staphylococcus vaccine for the treatment of acne; 
Neisser bacillus vaccine against gonorrheal infections as 
arthritis, cystitis, salpingitis, conjunctivitis, urethritis, 
etc.; staphylococcus vaccine for pus formations as fur- 
uncles, carbuncles, pleurisy, periostitis and ulcers, 
Streptococcus vaccine for scarlet fever, erysipelas, sep- 
ticemia and mixed infections. 

The vaccine is administered by means of a hypo- 
dermic syringe; the initial dose varies from 5,000,000 
to 1,000,000,000 bacteria. After injection there occur 
certain phases or reactions, known as the negative and 
positive phases. The negative phase is a condition in 
which the opsonins of the blood are decreased, and is 
clinically noted by the depressed state of the patient. 
The positive phase is marked by an increase of the 
opsonins in the blood, with general improvement of the 
patient's condition. 



CHAPTER XXVI 
BACTERIA 

In this chapter only such micro-organisms as are con- 
cerned in the diseases discussed in this book will be 
considered. 

A bacterium is a micro-organism of vegetable origin. 
Bacteria cause changes in the substance in which they 
grow and form new products in themselves which they 
retain or throw out. 

Classification. — -Bacteria are classified in several ways: 

Parasites and saprophytes; the former are called 
such because they subsist on living organic tissue; the 
latter live on dead material. 

Pathogenic and. non-pathogenic; the former are the 
cause of disease and the latter do not cause disease. 

Aerobic, those which require oxygen to maintain 
life. Non-aerobic, those which live without oxygen. 
Facultative, those which can grow with or without 
oxygen. 

Micrococci are bacteria consisting of spheric bodies 
which may vary in their arrangement. If the spheric 
bodies are in the form of a chain, then that micrococcus 
is known as a streptococcus; if in the form of a bunch 
of grapes, that is, grouped, it is a staphylococcus; if 
in pairs, then diplococcus; if in series of fours, then 
tetrads; if in cubic form, then sarcince. 

Bacilli are bacteria which appear as small rod-shaped 
bodies. 



BACTERIA 221 

Spirilla are bacteria which are curved. 

Growth. — 'Bacteria multiply by direct division, in 
which the bacterium is divided into two segments and 
each of these grow as separate individuals. Or they 
multiply by what is known as spore formation, in 
which small glistening bodies appear within the bac- 
terium, which are later set free and become independ- 
ent bacteria. 

Nutrition. — A medium for bacterial growth must 
contain nitrogen, which is supplied by albumen; car- 
bon, which is supplied by sugar; and the presence of 
moisture. The medium also should be neutral or 
slightly alkaline in reaction, and be kept at a tempera- 
ture of about q8°F. Bacteria will adapt themselves to 
the soil and temperature to which they are subjected. 

Media for the growth of bacteria are numerous; 
among the more common are the following: 

Bouillon, which is made by compressing cold beef 
and adding common salt and peptone to the juice. This 
juice is then boiled and filtered. 

Gelatine is made by adding ten per cent, of gelatine 
to the bouillon. 

Agar-agar, made by adding one per cent, of agar- 
agar to bouillon. Agar-agar, also known as Japanese 
gelatine, is a vegetable gelatine derived from a variety of 
seaweed growing along the coast of Japan. 

Other forms of media are blood serum, glucose, po- 
tato, milk, blood and peptone solution. 

Micrococci. — Staphylococcus Pyogenes Aureus. This 
is the most common bacterium of a pathogenic nature 
found in the body. It is the cause of the majority 
of the circumscribed purulent inflammations. It 
derives its name from the fact that it is composed of 



222 



FEVER NURSING 




Fig. 20. — Various Forms of Micro-organisms, i, Streptococci; 2, 
Staphylococci; 3, Diplococci; 4, Tetracocci; 5, Spirilla; 6, Bacilli; 7, Bacilli 
with spores. 



BACTERIA 223 

spheric bodies arranged in groups (staphylococcus), 
that its presence in the body is accompanied by the 
production of pus (pyogenes), and that if cultivated 
on media it produces colonies with an orange color 
(aureus). 

Other pathogenic staphylococci are the staphylococ- 
cus pyogenes albus and staphylococcus pyogenes citreus. 

Streptococcus Pyogenes. — 'This is also a common 
micro-organism and is the cause of most of the diffuse 
purulent inflammations. This bacterium is the cause 
of erysipelas. The secondary or mixed infections in 
pneumonia, tuberculosis, typhoid fever and diphtheria 
are due to the streptococcus pyogenes in a majority of 
cases. 

Pneumococcus . — 'This germ is the cause of lobar 
pneumonia. The pneumococcus is lance shaped and 
surrounded by a capsule. The coccus is very sensitive 
to light, heat, and to germicidal solutions. 

The pneumococcus is not only the cause of lobar 
pneumonia, but may also be the exciting agent of men- 
ingitis, peritonitis, pleurisy, pericarditis, endocarditis, 
and otitis media. 

Diplococcus Intracellular is Meningitidis. — "This bac- 
terium is the cause of cerebrospinal meningitis. The 
germ is composed of two spheric bodies and is usually 
found situated in the pus cells; hence its name. 

Bacilli. — -Typhoid bacillus was first described by 
Koch and Eberth. The bacilli occur as small, slender, 
rod-shaped bodies. They do not stain readily and in- 
oculations of the culture into animals are unsatisfac- 
tory as to results. 

The Widal Reaction. — If a drop of a typhoid 
bouillon culture be placed as a hanging drop on a glass 



2 24 FEVER NURSING 

slide and be examined under the microscope with an 
oil-immersion lens, the typhoid bacilli will be seen as 
small, rod-like bodies moving and wriggling about. 
If to this drop of culture be added some diluted serum 
obtained from a person supposed to be suffering from 
typhoid fever, the bacilli in a short time will become 
quiet and gather in groups if the person have typhoid 
fever. If the person be not afflicted with this disease, 
the movements of the typhoid bacilli are not altered 
by adding the serum to the culture drop. 

The typhoid bacilli are eliminated from the body of 
the individual especially by the bowel movements and 
the urine. 

Influenza bacillus or the bacillus of Pfeiffer is the 
exciting cause of influenza. The germ is very small 
and can be grown only in the presence of hemoglobin. 
It may persist in the nasal and pharyngeal cavities 
for months after the patient has recovered from the 
disease. 

Outside of the human body this germ has but little 
vitality; it dies in a few hours and cannot live in dried 
sputum. 

Diphtheria bacillus is also called the Klebs-Loffler 
bacillus from the men who first described it. The bacil- 
lus is irregular in its outline, occurring as straight or 
curved rod-like bodies with clubbed ends. They are 
found in diphtheria on the surface of the affected mu- 
cous membrane. They here form certain toxines which 
are absorbed and cause the general symptoms of a 
toxemia. Locally the bacilli cause a death and lique- 
faction necrosis of the superficial layers of the mucous 
membrane, forming a false or pseudomembrane. 

To combat the toxines of this bacillus a substance 



PLATE I. 




Streptococcus pyogenes (,X 700). 




Bacillus pneumoniae, (X 800 
a, as seen in sputum. 




Bacillus influenzae in nasal secre- 
tion, ( ,< 1000). 





Bacillus typhosus, a, ordinary 
form (X Jooo) ; />, flagellate 
form (X 1500). 




Micrococcus meningitidis 
cerebrospinalis, (X 1000). 



Bacillus tuberculosis; <rz,(Xiooo); 
b, ramified or branching form. 



BACTERIA 225 

known as antitoxin has been found. (See Chapter 
XXV.) 

Tubercle Bacillus. — This bacillus occurs as small 
slender rods slightly bent or curved. They do not 
produce spores and grow with difficulty on media. 
They are very resistant to outside influences and will 
live for a great length of time in dried sputum. 

Tuberculin. — -This substance when injected into a 
person will produce a certain reaction and is of diag- 
nostic value. The reaction is local and general. The 
local reaction consists of redness, swelling, and tender- 
ness; the general reaction consists of a rise of tempera- 
ture, general malaise, pain in the back, head and legs, 
nausea and vomiting, and at times a diffuse eruption. 

Tuberculin is prepared by taking a five-week gly- 
cerine-broth culture of tubercle bacilli and evaporating 
it to one-tenth of its original volume, and filtering. 

The test is made by injecting into the person one- 
half milligram of tuberculin. In twelve hours the re- 
actions discussed above will appear. If no reaction 
occur, the test should be repeated in a few days, using 
more of the tuberculin. The usual place to give the 
injection is in the skin between the scapulae. 



is 



CHAPTER XXVII 
URINE AND ITS EXAMINATION 

Urinalysis is one of the most positive methods for 
determining the presence of many important abnor- 
malities of the human organism. It is too frequently 
ignored by the medical man, or it is rapidly and improp- 
erly conducted, therefore valueless and misleading. 
It is important that every nurse should be thoroughly 
acquainted with physiological and pathological forms 
of urine, regarding its properties and constituents. 

Collection of Urine. — The urine to be preferred for 
examination is a four-ounce specimen of a twenty-four- 
hour collection. A statement of the amount of urine 
passed by the patient in the given twenty-four hours 
should accompany the specimen. If it is impossible to 
obtain a twenty-four-hour specimen, then the first urine 
voided in the morning is the next to be preferred. 

Urine for examination should be collected in an ab- 
solutely clean vessel and protected with a covering. 

We will now consider the properties of urine. 

Properties 

Quantity. — Normal. The amount of urine voided in 
twenty-four hours varies considerably according to the 
season, the amount of liquid taken, the profuseness of 
sweat, etc. From forty to sixty ounces are normal. 

It is increased in cold weather; when the amount of 
water ingested is large; in constipation, and by use of 

226 



URINE AND ITS EXAMINATION 227 

diuretics. It is decreased in warm weather; when the 
amount of water taken is small; and when sweating is 
profuse. 

Increased (polyuria) in diabetes mellitus; diabetes 
insipidus; chronic interstitial nephritis; hysteria; cardiac 
hypertrophy; after epileptic attacks, and during con- 
valescence from typhoid fever and pneumonia, and nerv- 
ous excitement. 

Decreased (oliguria) in fevers; acute nephritis (three 
to six ounces); chronic parenchymatous nephritis; 
cardiac failure; diarrheal diseases; anemia; emphysema; 
shock and collapse; the administration of drugs, as 
turpentine, cantharides, digitalis and ether (inhalation). 

Color. — -Normal. Urine is, physiologically, of a light 
amber color and clear, but its color varies with the 
amount of urine voided. 

Abnormal. — Pink cloudiness is due to an excess of 
amorphous urates. 

White or yellow haziness may be produced by an ex- 
cess of phosphate or the presence of mucus or pus. 

Dark amber, in diseases with decreased urine, as 
fevers, acute nephritis. 

Milky urine is due to the presence of chyle, and the 
condition is termed chyluria. 

Red-brown, or what may be appropriately called beef- 
brine, urine is due to the presence of blood, and is known 
as hematuria. It occurs in acute nephritis, renal injury, 
renal calculosis, cystitis, stone in bladder, etc., and 
during the administration of turpentine, cantharides 
and urotropin, in toxic doses. 

Golden-brown urine results from the presence of bile 
coloring matter and occurs in obstructive jaundice, 
and the condition is called biliuria vocholuria. 



2 28 FEVER NURSING 

Black or greenish-brown coloration follows poisoning 
from phenol derivatives, as carbolic acid, creosote, 
lysol and tar. 

Yellow urine is frequent after the administration of 
senna, santonin, picric acid. 

Blue or green urine follows the medicinal use of meth- 
ylene blue. The patient should always be informed 
of this change of color. 

Red urine is due to the presence of hemoglobin, and 
the condition is termed hemoglobinuria. Hemoglobin 
occurs in the urine in scurvy, pernicious anemia, malaria, 
and after poisoning by trional, potassium chlorate and 
toxic mushrooms. The urine is bright red after the ad- 
ministration of logwood and fuchsin. 

Pale urine occurs in diseases characterized by polyu- 
ria, as hysteria, diabetes, chronic interstitial nephritis, 
and at the crisis of febrile disorders. 

Odor. — -Normal. Not much can be said of the odor 
of urine, except that it is characteristic and urinous. 

Abnormal. — Certain drugs and foods alter the odor 
of the urine, as asparagus, copaiba, valerian, musk and 
asafcetida. 

Sweetish odor of the urine occurs in diabetes mellitus. 

Violet-like odor follows the administration of turpen- 
tine. 

Ammoniac odor may be present when the urine is 
voided, or may develop soon after being passed. It 
occurs in certain types of cystitis. 

Fecal odor to the urine may be due to the presence 
of material which has escaped from the bowel into the 
bladder through a fistula. A similar odor is due to 
decomposing pus in the bladder. 



URINE AND ITS EXAMINATION 229 

Reaction. — -Normal urine has a slightly acid or neutral 
reaction. 

Abnormal. 

Hyperacid. — Urine is excessively acid in leucemia, 
rheumatism, lithiasis and chronic nephritis. 

Alkaline urine occurs in some forms of cystitis, in 
nervous dyspepsia, cachectic conditions, and after ad- 
ministering certain drugs, as citrates, tartrates and bi- 
carbonates. 

Specific Gravity, or Density. — By the specific gravity 
of urine we mean the weight of a certain amount of urine 
as compared to the weight of a like quantity of distilled 
water at a certain temperature. This can very easily 
be computed by the use of a simple instrument known as 
an urinometer. 

Normal. — 'The density of urine voided by a healthy 
individual varies between 1015 and 1025. 

Higher. — The gravity is higher when the amount of 
urine voided is decreased (see Quantity.) 

Lower. — The gravity is lower when a large amount of 
urine is passed. 

A bnormal. 

High in diabetes mellitus (1070), acute nephritis, 
chronic parenchymatous nephritis, febrile conditions, 
diarrheal disorders and shock. 

Low in diabetes insipidus, chronic interstitial nephritis, 
hysteria (1000). 

Constituents 

Normal. — Urine is a watery fluid holding in solution 
certain salts, foremost of which are urea, uric acid and 
urates, phosphates, chlorids, sulphates and oxalates. 

Urea is one of the most important constituents of 



230 FEVER NURSING 

normal urine. It is freely soluble in water, hence never 
appears as a sediment. Urea is generally present in 
urine to the amount of two per cent. The daily output 
of urea can be easily computed by multiplying the quan- 
tity of urine voided in twenty-four hours by the per- 
centage of urea, and averages 500 grains. Urea is in- 
creased after meals rich in nitrogenous food and after 
drinking large quantities of water; it is decreased when 
the amount of food taken is small, when the bowels are 
loose, and when sweating is profuse. 

The excretion of urea is increased in fevers, diabetes, 
malaria, anemia, and after the crisis of pneumonia. It 
is diminished in all forms of nephritis, uremia, eclampsia, 
cachexia, rheumatism and nervous disorders. 

The estimation of urea will seldom be required of 
the nurse. For description of the method, consult some 
work on physiological chemistry. 

Uric acid and urates are present in the urine in small 
quantities. They are increased in fevers, tuberculosis, 
gout, rheumatism, leucemia, diabetes and rickets. 
After the excessive use of milk and certain drugs, as 
mercury, salicylates and colchicum, the amount of uric 
acid excreted is increased. 

They are diminished in anemia, nephritis, and after the 
use of iodids, lithium salts, sodium carbonate and chlorid. 

Chlorids. — -The chlorids in the urine are increased in 
malaria, diabetes and nephritis; are decreased in pneu- 
monia, rheumatism and some fevers. 

The excretion of phosphates is increased in nervous 
disorders. 

Abnormal. — The more important pathological con- 
stituents of urine are albumin, sugar, bile, blood, pus, 
mucus and acetone. 



URINE AND ITS EXAMINATION 23 1 

Albumin may be said to never occur in the urine 
normally, and is usually indicative of some patholog- 
ical change. The condition is known as albuminuria, 
and is met with in all forms of nephritis, especially the 
acute and chronic parenchymatous types; in febrile 
conditions, especially erysipelas, scarlet fever and diph- 
theria; in anemia, Grave's disease and leucemia; in 
cardiac disease, emphysema, cirrhosis of the liver; and 
after the toxic use of certain drugs, as lead, mercury, 
turpentine, cantharides and ether. 

The tests for the presence of albumin in urine are 
manifold. We will consider only three, which are simple 
and at the same time accurate: Nitric acid test, heat and 
nitric acid test, potassium ferrocyanide and acetic acid. 

Before testing urine for albumin there are two neces- 
sary requisites: the urine should be clear and of an 
acid reaction. If the urine is not clear, it must be fil- 
tered; if not acid, add dilute acetic acid until the specimen 
is slightly acid. 

Heat and Nitric Acid Test. — Fill a test tube three- 
quarters full with the urine to be examined; take hold 
of the bottom of the tube and hold diagonally in the 
flame of an alcohol lamp, or bunsen gas burner, so that 
the uppermost part of the urine is heated; allow it to 
boil for a moment. If no cloudiness or coagulum appear 
in the urine when heated, then albumin is not present. 
If a cloudiness does appear, it may or may not be in- 
dicative of albumin. This is positively established by 
adding to the heated urine a few drops of strong nitric 
acid, when the white cloud will disappear if not due to 
albumin (but phosphates); but if due to albumin, the 
cloudiness does not disappear but may increase. 

Cold Nitric Acid Test. — 'Place in a test tube pure nitric 



232 FEVER NURSING 

acid (about two drams), and then with a fine glass tube 
allow some of the suspected urine to gently flow upon 
the surface of the acid. If albumin be present, a ring 
of wmite coagulum will form at the point of contact of 
the fluids. 

Potassium F err cyanide. — This test is very simple, 
rapid and accurate. It requires no heat, and caustic 
acids are not employed. For these reasons I advise 
its application. 

To a test tube half full of clear urine, add two drams 
of a five per cent, solution of potassium ferrocyanide and 
mix intimately; then a few drops of acetic acid. If 
albumin is present, a white-yellow haziness or cloud 
will appear. 

Sugar. — Sugar which occurs pathologically in the urine 
is not of the cane-sugar type, but is of the same class as 
grape sugar. This condition is known as glucosuria 
and glycosuria. Sugar occurs in the urine in diabetes 
mellitus, obesity, diseases of the brain, especially when 
affecting the medulla; in certain affections of the liver 
and pancreas; during the administration of certain 
drugs, as chloral, alcohol, arsenic and chloroform (in- 
halation), and after the excessive use of sugar as a 
food. 

The tests for sugar in the urine are numerous. Those 
which we will consider are Fehling's, Haines' and 
fermentation tests. 

Fehling's Test. — To apply this test a special solu- 
tion is necessary, which is best preserved by having it 
prepared in two solutions. Solution 1, or the copper 
solution, consists of copper sulphate or blue vitriol (34 
parts) and water (1000 parts); and Solution 2, or the 
alkaline solution, consists of sodium-potassium tartrate 



URINE AND ITS EXAMINATION 233 

or Rochelle salts (173 parts), sodium hydrate or caustic 
soda (60 parts), and water (1000 parts). 

To prepare Fehling's solution, mix equal parts of 
Solutions 1 and 2. 

The test is applied by filling a test tube half full with 
the prepared solution and heating (boiling) the upper- 
most part; then add a few drops of the suspected urine to 
the hot solution, when a red-brown coloration and 
precipitate will occur if the sugar be present. 

Haines 1 Test. — This test is applied in the same manner 
as Fehling's, the difference being in the solution used. 
The Haines' solution is similar to the Fehling's solu- 
tion, excepting that glycerine is used in place of Rochelle 
salts, and is more stable. 

Fermentation. — This test is accurate, but more com- 
plicated than the above, and depends on the fermenta- 
tion of the sugar by yeast. 

Bile is present in the urine when the natural flow 
of bile is obstructed. The urine is of a golden-brown 
color. 

Gmelin's Test. — Into a test tube two drams of nitric 
acid is placed, and about the same quantity of the urine 
is allowed to gently flow on the surface of the acid. If 
bile is present, a series of colored rings, green, blue, 
brown or yellow, will form at the junction of the two 
liquids. 

Pus is found in the urine in purulent inflammation 
of the kidneys, bladder or urethra. 

Its presence is detected by the addition of caustic 
potash (potassium hydrate) and boiling the mixture, 
when a tenacious, ropy mass results. This is Donne's 
test. 



CHAPTER XXVIII 



SIGNS OF THE ONSET OF THE TOXIC 
EFFECTS OF DRUGS 

It is important that the nurse should be familiar with 
the action of certain drugs, so that in the absence of 
the physician if the full physiologic action of the drug 
be taking effect, further harm may be avoided. 

This list includes the more common and important 
drugs : 

Drug. Sign. 

Acetanilid. Cyanosis, sweating, feeble pulse and 

cold skin. 

Aconite. Tingling sensation of the skin, vom- 

iting, weak pulse. 

Arsenic. Pufriness of the lower eyelids, indiges- 

tion, diarrhea, headache. 

Bromids. Acneal eruption on the face and back, 

malaise, and indigestion. 

Belladonna. Dryness of the nose, mouth and throat; 
dilatation of the pupils; skin be- 
comes red and dry; dizziness; gid- 
diness. 

Carbolic acid. Headache, vomiting, diarrhea, darkly 
colored urine. 

Colchicum. Nausea, vomiting, purging, and weak 

pulse. 

234 



TOXIC EFFECTS OF DRUGS 



235 



Digitalis. Slow pulse, which becomes rapid and 

irregular if the patient sit up; pale- 
ness of the face; vomiting of mu- 
cus and bile. 

Ergot. Numbness, tingling sensation, feeling 

of cold, vomiting, purging, paleness 
of the surface. 

Iodids. Running of the eyes and nose, injec- 

tion of the conjunctivae, acneal erup- 
tion, diarrhea, and salivation. 

Mercury. Salivation, diarrhea, metallic taste in 

the mouth, sore gums, fetor of the 
breath, colicky pains, and paralyses. 

Nitroglycerine. Flushing of the face, throbbing head- 
ache, fullness of the head. 

Opium. Constipation, sweating, dryness of the 

mouth, contracted pupils. 

Quinine. Fullness of the head, buzzing and ring- 

ing in the ears, deafness, dizziness, 
and headache. 

Salicylates. See quinine. 

Strychnine. Twitchings of the body, restlessness, 

tingling sensation, and convulsions 
later. 

Turpentine. Violet-like odor to the urine, red erup- 
tion, painful urination, and bloody 
urine. 






CHAPTER XXIX 
POISONS AND THEIR ANTIDOTES 

Poisoning may be classified as acute and chronic. 
The acute form may result from an overdose of a drug 
taken by mistake or for suicidal purpose. The chronic 
form results from the continuous administration of 
a drug, or from being constantly in contact with cer- 
tain poisons, as a painter or type-worker becomes lead 
poisoned or workers in match factories suffer from phos- 
phorus poisoning. 

Treatment of Acute Poisoning. — The indications are: 
To remove the poison from the body as soon as pos- 
sible; to render inert the poison which cannot be re- 
moved; to counteract the toxic action of the poison, 
and to support the patient with stimulants, if necessary. 

Removal of the Poison. — This is brought about by 
emesis and catharsis. If there is reason to believe 
that some of the poison still remains in the stomach, 
emetics should be resorted to. Among the common 
and most used emetics are salt water, made by dis- 
solving a teaspoonful of salt in a cup of lukewarm 
water; ipecac (30 grains of the powder or 30 m. of the 
fluid extract); apomorphine, given hypodermically in 
doses of one-fifteenth to one-tenth of a grain. 

Cathartics may be used to remove the toxic material 
that has gained entrance to the intestines. 

To Render the Poison Inert. — This is made possible 
by the use of antidotes which act either mechanically 

236 



POISONS AND THEIR ANTIDOTES 237 

or chemically. The mechanical antidotes decrease the 
toxic effects of poisons by preventing or lessening their 
absorption, and are principally fixed oils, as cotton-seed, 
olive or linseed oils; also milk, starch paste and gummy 
or mucilaginous drinks, as flaxseed and slippery elm 
teas. The chemical antidotes render the poisons inert by 
neutralizing them or changing them into less toxic or non- 
poisonous substances. The chemical antidotes to acids 
are limewater, chalk, magnesia, bicarbonates, milk, white 
of egg, etc. The chemical antidotes of alkalies are diluted 
acids, lemon juice, vinegar, acid lemonade, white of 
egg, milk, etc. The chemical antidotes to alkaloids are 
tannic acid, potassium permanganate, strong tea. 

To Counteract Poisons. — This is brought about by 
giving drugs whose actions are diametrically opposed 
to the actions of the poison taken. Here are given a 
list of drugs, with their antagonists: 

Aconite, aconitine (digitalis, atropine). 

Atropine, belladonna (morphine, eserine, pilocarpine, 
aconitine). 

Belladonna. See atropine. 

Chloral (strychnine, amyl nitrate). 

Cocaine (strychnine, alcohol, nitroglycerine). 

Digitalis (nitroglycerine, aconite, senega). 

Hyoscine (pilocarpine, morphine). 

Hyoscyamus. See atropine. 

Morphine (atropine, strychnine, caffeine). 

Nitroglycerine (ergot, atropine, suprarenal extract). 

Nux vomica. See strychnine. 

Opium. See morphine. 

Physostigmin, or eserine (atropine, strychnine). 

Pilocarpine (atropine, alcohol). 

Strychnine (chloral, bromids, morphine, eserine). 



238 



FEVER NURSING 



Veratrum viride (atropine, digitalis). 

Stimulation is necessary in all cases of severe poi- 
soning. The most used are: ammonia (aromatic spirits), 
ether, alcohol (brandy, whiskey), digitalis, strychnine, 
atropine and amyl nitrite. 



Special Antidotes 
Poison 
Acetanilid, antipyrine, phen- 
acetin, migraine tablets, 
and headache cures. 
Acid, carbolic, salol, creo- 
sote, etc. 



Antidote 
Plenty of air, hot applica- 
tions, and stimulation. 



Acid, hydrocyanic. 
Amyl nitrite, nitroglycer- 
ine and the nitrites. 

Arsenic, Fowler's, Pierson's 
and Donovan's solutions, 
Paris green, etc. 



Belladonna, atropine, and 

hyoscyamus. 
Bromids. 
Castor oil beans. 

Chloral. 

Cocaine. 



Whiskey by mouth, soluble 
sulphates, as Epsom or 
Glauber salts, white of 
egg, milk, and stimu- 
lants. 

Oxygen and stimulants. 

Fresh air, tincture of digi- 
talis and other stimu- 
lants. 

Dialyzed iron, iron hy- 
drate (mix dilute am- 
monia water with a 
solution of iron sul- 
phate). 

Morphine and stimulants. 

Stimulants. 

Opium for the colic and 
stimulants. 

Strong coffee and strych- 
nine. 

Stimulants and oxygen. 



POISONS AND THEIR ANTIDOTES 



239 



Digitalis, squill, strophan- 

thus, and convallaria. 
Lead compounds. 



Mercury. 

Opium, morphine, and co- 
deine. 



Phosphorus, matches, rat 

poison. 
Poison-ivy. 



Strychnine. 
Sulfonal, trional, etc. 

Veratrum. 



Saline cathartics and 
stimulants. 

Sulphuric acid, lemonade, 
milk, white of egg, sa- 
line cathartics, hot fo- 
mentations, opium for 
the cramps, and the io- 
dids. 

See lead. 

Potassium permanganate 
by mouth and hypo- 
dermically, tannic acid, 
coffee, atropine, flagella- 
tion. 

Oil of turpentine, Epsom 
salts, and stimulants. 

Apply fluid extract of 
grindelia, saleratus, or 
lead acetate solution. 

Chloral, bromids, and 
stimulants. 

Sodium bicarbonate, 
strong coffee, and stimu- 
lants. 

Stimulants. 



CHAPTER XXX 
ENEMATA AND TOPICAL APPLICATIONS 

ENEMATA 

The uses of enemata are: To clean out the lower 
bowel; to supply nourishment; to introduce water 
into the system; for medication, both general and local. 

To Clean Out the Lower Bowel. — Soapsuds. Agi- 
tate one ounce of soft soap with one and one-half pints 
of warm water. 

Glycerine. Equal parts of glycerine and water, about 
one ounce of each. 

Purgative. To one pint of soapsuds (see above) 
add one ounce of Epsom salts, one dram to one-half 
ounce of turpentine, and one ounce of glycerine. 

Oxgall. To the purgative enema add ten grains of 
powdered inspissated oxgall. 

Oil. One pint of warm cotton-seed oil. 

Nutritive Enema. — Oftentimes because of inability 
from various causes to give food by mouth, it becomes 
necessary to resort to nutritive injections. In order to 
properly give this form of enema, the patient should be 
placed on his left side with thighs flexed. A lubricated 
catheter should then be introduced into the rectum four 
to eight inches and connected with the tubing of a foun- 
tain bag placed two to three feet above the patient. 
These injections may be given every six to eight hours. 
The fluid to inject may consist of peptonized milk 

240 



ENEMATA AND TOPICAL APPLICATIONS 24 1 

alone or combined with beaten white of egg. To a child 
of three months about three ounces of food may be 
given; at six months, five ounces; at one year, seven 
ounces; over two years, one-half to one pint. 

To Introduce Water. — Useful in septicemia, shock 
and hemorrhage. Use normal saline solution. 

For Medication. — Uses: As a local medication; be- 
cause of the ill taste of certain medicines; inability 
to take medicines by mouth, as in coma, because of nausea 
and vomiting, or disease of the stomach. 

Medicines most commonly given per rectum are 
chloral, bromids, digitalis, and whiskey. 

Asafcetida. — This is given for the purpose of reliev- 
ing distention of the abdomen and colic. It is espe- 
cially useful in the colic of infants. Take four ounces 
of the emulsion of asafcetida (made by agitating one 
dram of powdered asafcetida with four ounces of water) 
and four ounces of warm water. 

Turpentine. — Also used to relieve tympanites: 

Turpentine, 1 dram to 1 ounce. 
Olive oil, 3^ to 2 ounces. 
Warm water to 4 ounces. 

Quassia is used for pinworms in the rectum. To 
one dram of quassia add one-half pint of cold water, 
and allow to stand for three hours; then strain and use 
all for one injection. 

Starch and Laudanum. — To some powdered starch 
add a small quantity of cold water and stir thoroughly. 
Then add sufficient boiling water to make a thin, clear, 
mucilaginous liquid. To one ounce of this solution 
add one to fifteen minims of laudanum. 
16 



242 FEVER NURSING 



TOPICAL APPLICATIONS 



Poultices. — The uses of poultices are chiefly two- 
fold: to apply heat and moisture. They relax the 
vessels and relieve tension and pain. The secret of 
making poultices consists in stirring the material into 
the boiling water and spreading it on hot cloths in a 
thick layer. Let the poultice remain on the surface of the 
body until cool and then replace with another. 

Flaxseed. — Onto boiling water sprinkle ground flax- 
seed meal and stir vigorously, adding more meal until 
the mixture assumes the consistency of porridge. Then 
spread on the cloth. 

Mustard. — Into a thin flaxseed meal poultice stir 
ground mustard in the proportion of from one to two, 
to twelve, according to the age of the patient and the 
desired action. 

Bran. — Make a small bran cushion or pillow and pour 
over it boiling water; then wring it dry in a towel. 

Bread. — Take thick slices of bread and pour on boil- 
ing water for five minutes; then break the bread and 
apply as a poultice. 

Another method is to let the bread simmer for five 
minutes in the water, when the bread becomes pulpy. 
Apply. 

Charcoal. — This form of poultice is very useful for 
removing the odor of putrid ulcers. To the bread or 
flaxseed poultice add powdered charcoal. 

Counter -irritation. — In congestion and inflammation 
the little blood-vessels of the affected part are enlarged 
and contain more blood than normal, hence there is a 
reddening of the tissues. By applying to the skin cer- 
tain drugs a congestive or irritative red area appears and 



ENEMATA AND TOPICAL APPLICATIONS 243 

thus the seat of real congestion or inflammation is re- 
lieved of some of its blood. This process is known as 
counter-irritation. This medical procedure is very use- 
ful in bronchitis, pneumonia, pleurisy, neuralgias, pain 
of the congestive type, joint pains and colics. Of the 
household means, turpentine, mustard, kerosene, cam- 
phor and iodine are most commonly employed. 

Mustard is employed in the form of a plaster, bath and 
pack. A mustard plaster for a child should be weak, one 
part mustard to three or four parts of flour, thoroughly 
mixed and stirred into a paste with lukewarm water, then 
spread on a cloth and applied to the part. When the 
skin is reddened (not blistered) the plaster is removed and 
the skin anointed with vaseline or sweet oil. 

The mustard bath is made by adding to five gallons of 
warm water a tablespoonful of ground mustard. The 
child is placed in the bath and the skin gently rubbed 
until it glows, care being used to get none of the solution 
in the eyes. The child is then dried and placed in bed. 

The mustard pack is a very fine form of counter-irrita- 
tion in bronchitis and pneumonia. Into four ounces of 
alcohol put ten drops of the essential oil of mustard and 
add this mixture to three cupfuls of water, moisten a 
large piece of white flannel with it and wrap the cloth 
around the child from neck to navel, then envelop the 
child in a dry sheet until skin glows, which usually takes 
fifteen to thirty minutes, when the pack may be removed. 
This may be repeated twice or thrice in twenty-four 
hours if the skin condition will permit. 

Turpentine is usually used in the form of turpentine 
and lard. This is now preferably succeeded by a mix- 
ture of camphorated oil and turpentine. A turpentine 
stupe is made by immersing a woolen cloth in hot water 



244 FEVER NURSING 

containing fifteen to thirty drops of turpentine, and 
then applying to the body. This is especially used as 
an abdominal application in distention of the bowels 
with gas. 

Kerosene is used for counter-irritation to quite an ex- 
tent in the home. Nothing will be said of it here as we 
have other and better agents for this purpose. 

Camphor in the form of camphorated oil is a very 
useful application, especially immediately after a mus- 
tard paste has been removed. 

Iodine as tincture of iodine is an excellent drug for 
this purpose if rightly applied. At the first application 
four to six coats of the tincture should be put on, so that 
the skin takes on a very dark appearance, then no more 
should be used until the color of the skin is about 
natural. This may be a day or more. 

Stupes. — Turpentine. Pour on a piece of flannel 
some very hot water; then wring the flannel dry in 
a towel and sprinkle with twenty to fifty drops of 
turpentine. 

Another method is to add to one quart of boiling 
water one teaspoonful of turpentine; into this im- 
merse the flannel and wring dry in a towel. 

Chloroform and Turpentine. — Same as the turpen- 
tine stupe, adding five to fifteen drops of chloroform. 



CHAPTER XXXI 
ANTISEPTICS AND DISINFECTION 

Bichlorid of mercury is used in watery solutions of 
from i to 500 to 1 to 1000. The most common dilu- 
tion is the latter. This solution is used for the disin- 
fection of the hands and tissues. For irrigating or for 
use in the abdomen weaker solutions, as from 1 to 2000 
to 1 to 10,000. Bichlorid is liable to coagulate the al- 
bumen of the tissues and thus prevent deep disinfection. 

Bichlorid of mercury should not be used to sterilize 
metallic instruments as it corrodes them and destroys 
the edges of sharpened instruments. 

Toxic effects may result from the absorption of mer- 
cury through the skin. The signs are salivation, sore 
gums, foul breath, abdominal colic, diarrhea, etc. 

In preparing solutions of the bichlorid of mercury 
it is best to add common salt, ammonium chlorid or 
citric acid, as these prevent the decomposition of the 
bichlorid. 

Carbolic acid is next in importance. It is used in 
solutions ranging from 1 to 10 to 1 to 100. A 1 to 20 
solution is most generally used for sterilizing instru- 
ments. A 1 to 100 solution is used for packs and 
irrigation. 

Signs of carbolic acid poisoning are headache, diz- 
ziness, vomiting, painful urination, dark-colored urine, 
and diarrhea. Local gangrene has resulted from the 
application of weak solutions of carbolic acid. 

245 



246 FEVER NURSING 

Potassium permanganate is used for douches in a 
solution of 1 to 1000. 

Iodoform is used especially in tubercular disease 
as iodoform gauze, emulsion, or powder. 

Formaldehyd in two per cent, solutions for steril- 
izing the hands or instruments. 

Hydrogen peroxid, used in the strength dispensed 
or diluted, is especially useful in cleansing pus cavities. 

Creolin is used in two and four per cent, solutions 
for douches and irrigation. 

Boric acid as a weak antiseptic for the eyes, nose 
and bladder. 

Lysol, to be used as creolin. 

Aristol has the same use as iodoform and is nearly 
free from odor. 

Chlorinated lime is useful for disinfecting the ex- 
creta of the body. 

TABLE OF SOLUTIONS 

To one pint of water or the solvent used, add the 
following quantities of the chemical or drug: 

For a 1 to 5000 or a 1-50 per cent, solution use 1% 
grains. 

For a 1 to 2000 or a 1-20 per cent, solution use 3% 
grains. 

For a 1 to 1000 or a 1-10 per cent, solution use 7^ 
grains. 

For a 1 to 100 or a 1 per cent, solution use 73 grains. 

For a 1 to 20 or a 5 per cent, solution use 365 grains. 

For a 1 to 10 or a 10 per cent, solution use 730 grains. 

Note. — To one ounce of water add one dram of 
chemical, and one dram of this solution when added to 



ANTISEPTICS AND DISINFECTION 247 

one pint of water will give approximately a 1 to 1000 
solution. 

The New York State Department of Health issues 
a very instructive circular on "Disinfection and Dis- 
infectants," which is here given in part: 

Disinfection and Disinfectants 

For the prevention of the spread of contagious and 
most infectious diseases nothing is more important 
after the diagnosis of the case than the proper care 
of the various discharges or excretions from the eyes, 
nose, mouth, skin, and of the excreta of the bowels 
and bladder of the sick. 

As the diagnosis of the disease cannot always be 
made as soon as some of these discharges or excreta 
become dangerous to others, every person suspected of 
having either consumption, typhoid fever, diphtheria, 
smallpox, measles, whooping-cough or cerebrospinal 
meningitis should be treated as if the diagnosis had 
been made positively. 

SICKROOM AND ITS CARE 

Above all else, cleanliness must be observed. All 
other precautions are likely to fail in its absence. 

1. The patient should be placed in an isolated room 
which should have in it as little furniture as possible. 
Iron bedsteads and plain wooden furniture are the 
most suitable. Carpets, draperies and curtains should 
be removed. A sheet kept moistened with carbolic solu- 
tion (1-40) or bichlorid solution (1-1000) should be hung 
from the top of the door. The floor, woodwork and 
furniture should be wiped daily with a cloth moistened 



248 FEVER NURSING 

preferably with carbolic solution (1-40). The floor 
should not be swept while dry. It should be sprinkled 
with sawdust, bran or other granular material thor- 
oughly moistened with carbolic solution (1-20), and 
then carefully swept so that no dust may arise. Flies 
should be absolutely excluded from the sickroom. For 
this purpose mosquito netting should be tacked on the 
window frames outside so that each entire window is cov- ' 
ered, and a screen door should be put up at the entrance 
to the room if flies are not excluded from the entire house. 
The sheet moistened with carbolic solution may be hung 
on this door. Household pets must be excluded. 

2. Plates, cups, glasses, knives, forks, spoons and 
all other utensils used by the patient should be kept for 
his use alone, and under no circumstances should they be 
removed or mixed with similar utensils used by others. 
They should be placed in carbolic solution (1-20) imme- 
diately after use and remain there for an hour or longer, 
after which they should be washed in hot, strong soap- 
suds and rinsed with boiling water. 

3. The patient's clothing, the sheets, pillow cases, 
towels, napkins and other clothing which have been in 
contact with the patient should be placed after use into 
carbolic solution (1-20) or bichlorid solution (1-500) 
for at least one hour, after which they should be thor- 
oughly washed. The outside clothing worn by the 
attendant should be treated in the same manner. 

4. Any articles or surfaces soiled by discharges 
should be immediately washed with carbolic solution 
(1-20). 

5. The discharges from the nose, mouth, ears or eyes 
should be received on cloths or paper napkins, and 
these, together with remnants of food, should be burned 



ANTISEPTICS AND DISINFECTION 249 

at once by the attendant. If handkerchiefs are used 
they should be immersed in carbolic solution (1-20) be- 
fore the discharges dry. 

6. In cases of typhoid fever, scarlet fever and dys- 
entery the discharges from the bowels and the urine 
should be received into bedpans or other vessels con- 
taining small amounts of either carbolic solution (1-20), 
bichlorid solution (1-500), or chlorid of lime solution, 
and a quantity of the same disinfectant equal in volume 
to that of the discharges should be added, and the whole 
protected from flies and allowed to stand for one hour 
and then dumped into the water-closet. If only a privy 
is available, fresh chlorid of lime should be added, 
followed by earth or ashes; or the disinfected stools may 
be buried in a trench, which must be remote from and, 
if possible, down hill from the well or nearest water- 
course. The trench should be four feet deep and two wide, 
and each deposit should at once be well covered with 
quicklime and earth well beaten down, the trench being 
covered in with earth when half filled in this manner. Or 
the discharges may be mixed with sawdust and kerosene 
and placed in a water-tight kerosene barrel, and after 
recovery or death add more kerosene and burn the 
entire barrel and contents. 

7. The body of the patient should be washed daily 
with warm water, or as directed by the physician, and 
the water that has been used in such baths should have 
added to it an equal quantity of chlorid of lime solu- 
tion or carbolic acid solution (1-20) and allowed to 
stand for one hour, when it can be emptied down the 
water-closet or into the privy. 

8. After making applications to the throat, nose, 
ears, eyes or after handling the patient in any way, 



250 FEVER NURSING 

before eating, or leaving the sickroom, the hands of 
the attendant should be immersed in carbolic solution (1-40) 
or bichlorid solution (1-1000) and then thoroughly 
rubbed in hot soapsuds. 

Upon notice from the health officer or physician 
that the sickroom is ready for disinfection, everything 
which has been used by the patient or attendant during 
the illness should be allowed to remain in the room 
for disinfection. 

10. If the disease should terminate fatally, the body 
should be wrapped in a sheet saturated with corrosive 
sublimate solution (1-500) and placed in a tight coffin, 
which should not be opened afterward, and burial 
should take place within twenty-four hours, if possible. 

DISINFECTION OF ROOMS 

Preparation of Room. — 1. Carefully close all windows 
and doors, except one door for exit. Paste paper over 
stovepipe hole, and over all window, transom or door 
cracks. In a word, seal the room tightly from the 
inside. 

2. Open closet doors, drawers, trunks, boxes, etc. 
Suspend clothing and bedclothes upon lines stretched 
across the rooms, or spread out on chairs or clothes- 
horses. Books must be opened and the leaves spread; 
in short, the room and its contents must be so disposed 
as to secure free access of gas to all parts and to all 
objects. 

3. The next point is to make the air in the room damp; 
this is absolutely necessary for disinfection, either 
by sulphur or formaldehyd. Dampness may be pro- 
duced (a) by boiling water on a gas or gasoline stove; 
(b) by pouring boiling hot water from a teakettle into a 



ANTISEPTICS AND DISINFECTION 25 1 

tub; (c) by pouring cold water onto hot bricks or stone, or 
by dropping hot bricks or stones into vessels containing 
cold water. Under no circumstances is efficient disin- 
fection possible without in some way making the air of the 
room quite damp. The temperature should also be 
6o° F. or over. 

4. Measure the room, and get the length, breadth 
and height in feet. Multiply the figures together, dis- 
regarding the fractions. This will give the cubical 
contents of the room in feet. Divide by 1000, and we 
know the number of thousand cubic feet in the room. 
Example: Suppose a room to be 24 feet long, 13^ 
feet wide and 12% feet high. Disregarding fractions, 
the cubical contents of the room is 24 X 13 X 12 
(= 3744) cubic feet, and the number of thousand cubic 
feet is 37 or, approximately, 3^. 

Sulphur Disinfection. — For each 1000 cubic feet, 
weigh out four pounds of powdered or roll sulphur 
and place it in an iron kettle or dishpan, or take four 
tins of pressed sulphur, or four one-pound sulphur 
candles, setting the last in saucers. For the room 
mentioned in the above example, fifteen pounds of sul- 
phur would be used. Stand the dishpan, tins or saucers 
in a tub containing two inches or more of water, and place 
the same on a table; do not put it on the floor. The 
water is put in the tub to guard against fire; it must not 
come in contact with the sulphur, and bricks can be placed 
under saucers to prevent this. Dampen the powdered 
or roll sulphur in a spot not larger than a silver dollar 
with alcohol or coal oil, and apply a match to the same 
or to the wicks of the candles. Without delay, retire 
from the room, closing the door, and paste paper on the 
outside of the keyhole and cracks. The room must re- 



252 FEVER NURSING 

main closed for at least ten or, better, twenty-four hours. 
When the time is up, the windows should be opened, if 
possible from the outside, and the room thoroughly aired. 
The room and contents may now be considered free from 
infection, if the work has been properly carried out, but 
any mattresses, rugs, carpets, blankets and other unwash- 
able materials must be hung in the open air and sun- 
shine for several days. Sheets, pillow cases, bed- 
clothes and the patient's and attendant's clothing should 
be thoroughly washed, using boiling water. The floor, 
woodwork, bureau, bedstead, table and chairs must be 
washed with soap and water. 

Disinfection with Formaldehyd Gas. — Prepare the 
room as described above. Take one pint of forty per 
cent, solution of formaldehyd and eight ounces of crys- 
talline permanganate of potassium for each 1000 cubic 
feet. The room mentioned above would need three and 
three-quarter pints of formaldehyd and thirty ounces of 
permanganate. Place the permanganate in a dishpan, 
stone crock or other vessel large enough to hold as many 
gallons as there are pints of formaldehyd. This is to 
make sure the liquid will not boil over. Set the pan or 
crock inside of a slightly larger wooden pail, tub or crock, 
to retain the heat generated in the mixture; or wrap the 
pan or crock in two layers of asbestos paper or blankets. 
Now the vessel containing the permanganate is placed 
in the center of the room and the formaldehyd is poured 
onto it from a pitcher. The operator must immediately 
retire from the room and close the door. Keep the 
room closed for six to ten hours, then open all win- 
dows and doors and air thoroughly. Finally, clean all 
the contents of the room, as directed after sulphur 
disinfection. 



ANTISEPTICS AND DISINFECTION 253 

Formaldehyd gas does not injure fabrics nor metals 
as does sulphur. It must not be breathed, and it would 
be well not to have the strong liquid formaldehyd come 
into contact with the skin. Formaldehyd disinfection 
can be accomplished in other ways very satisfactorily, 
but such methods should be used only by those having 
considerable training and experience with methods of 
room disinfection. Do not use any methods unless the 
same have been personally recommended to you by a 
physician or a person expert in the details of room 
disinfection. Do not rely upon patented solutions and 
methods. 

Disinfection of Clothing. — If one's clothing becomes 
infected by visiting cases of measles, scarlet fever, 
diphtheria, etc., or in any way, it may be disinfected 
with formaldehyd as follows: Place the clothing in a 
trunk, wash-boiler or covered box, one piece at a time, 
covering each piece with a towel, pillow-slip, sheet or 
piece of cloth, and sprinkle or spray on each cover, as 
it is laid on, two tablespoonfuls of forty per cent, for- 
maldehyd. When the trunk or boiler is full, put on 
the cover and let stand for six hours, then open and 
air the clothing. Each piece of clothing must be 
covered to protect it from being spotted by the 
formaldehyd. 



CHAPTER XXXII 

ABBREVIATIONS, WEIGHTS AND 
MEASURES 

ABBREVIATIONS 

Aa. — Of each. 

A. C. — Before Meals. 
Aq. — Water. 

Aq. Bui. — Boiling Water. 
Aq. Dest — Distilled Water. 
Aq. Ferv. — Hot Water. 
Aq. Font. — Spring Water. 
Bene.— Well. 

B. I. D — Twice a Day. 
C— With. 

Cochl. — Spoonful. 

Cras. — To-morrow. 

D — Dose. 

Ft.— Make. 

Gr. — Grain. 

Gm. — Gram. 

Gtt— Drop. 

M— Minim. 

O— Pint. 

P. C.— After Meals. 

Q. 4. H. — Every Four Hours, 

Q. S— Sufficient Quantity. 

Sine.— Without. 

2 54 



ABBREVIATIONS, WEIGHTS AND MEASURES 255 

Stat. — Immediately. 

T. I. D— Three Times a Day. 

IV. I. D. — Four Times a Day. 

WEIGHTS AND MEASURES 

Apothecary's Weight. 

60 Minims, 1 Dram. 
8 Drams, 1 Ounce. 
16 Ounces, i Pint. 



Troy Weight. 



20 Grains, 1 Scruple. 
3 Scruples, 1 Dram. 
8 Drams, 1 Ounce. 



Metric Values. 






0.0081 Gram, 1-8 Grains. 




0.056 Gram, 7-8 Grains. 




0.1 Gram, 1.54 Grains. 




0.5 Gram, 7.71 Grains. 




0.9 Gram, 13.89 Grains. 




1. Gram, 15.43 Grains. 




1. CC., 16.23 Minims. 


Equivalents. 






1 Grain, 0.065 Grams. 




2 Grains, 0.13 Grams. 




5 Grains, 0.324 Grams. 




15 Grains, 0.972 Grams. 




480 Grains, 31.103 Grams, 




1 Minim, 0.0616 CC. 




2 Minims, 0.1232 CC. 




5 Minims, 0.3080 CC. 




60 Minims, 3.7 CC. 




480 Minims, 29.6 CC. 



256 



FEVER NURSING 



i Pint, 0.473 Liters. 
1 Quart, 0.946 Liters. 
1 Gallon, 3.784 Liters. 
1 Liter, 33.8 Ounces. 

Domestic Measures. 

1 Teaspoonful, 1 Dram or 4 CC. 
1 Dessert-spoon, 2 Drams or 8 CC. 
1 Tablespoon, 4 Drams or 16 CC. 
1 Wine glass, 2 Ounces. 
1 Tea cup, 5 Ounces. 
1 Tumbler, n Ounces. 



Centigrade. 



Thermometric 


Equivalents. 




212. Fahrenheit — 


100. ° 


120. 






49. 


ioo.° 






37-77 


98.6 






37-° 


8o.° 






27.° 


6o.° 






16. 


5o.° 






IO.° 









O 


32. 






O. 



- 17-78° 

To reduce Centigrade to Fahrenheit, multiply by 
nine and divide by five, and add thirty-two. 

To reduce Fahrenheit to Centigrade, subtract thirty- 
two, multiply by five, and divide by nine. 



CHAPTER XXXIII 
SELECTED FORMULAS 

Bichlorid of Mercury (i-iooo) 

Bichlorid of Mercury about 7% grains. 
Common Table Salt, about 8 grains. 
Boiled Water 1 pint. 

Note.— This solution is extremely poisonous and 
should only be used externally and for disinfecting 
purposes as described in the text or by the attend- 
ing physician. 

Bichlorid of Mercury (1-5000) 

Bichlorid of Mercury about 1 Y^ grains. 
Boiled Water 1 pint. 

Note. — Poisonous. 

Carbolic Acid (5 per cent, or 1-20) 

Crystal Carbolic Acid about 6^ drams. 
Hot Water 1 pint. 

Shake well before using. Poisonous. 

Carbolic Acid (1 per cent, or 1-100) 

Crystal Carbolic Acid about iJi drams. 
Hot Water 1 pint. 

Poisonous. 

Formaldehyd Solution (1 per cent, or 1-100) 

Formalin about ij£ drams. 

Boiled Water ' 1 pint. 

17 257 



25« 



FEVER NURSING 



Creolin Solution (i per cent, or i-ioo) 

Creolin about iJ/£ drams. 

Boiled Water i pint. 

Potassium Permanganate Solution (i-iooo) 

Potassium Permanganate Crystals 7^ grains. 
Boiled Water 1 pint. 

Note. — The stains on clothing from this solution are 
difficult to remove. 

Boric Acid Solution (4 per cent, or 1-25) 
Boric Acid Crystals about • 

Boiled Water (warm) 

Boric Acid Solution (1 per cent, or 1-100) 
Boric Acid Crystals about 
Boiled Water (warm) 

Mouth Wash (No. 1) 

Boric Acid Crystals about 

Glycerine 

Juice of Half Lemon 

Warm Water 

Mouth Wash (No. 2) 

Potassium Permanganate Crystals 
Warm Water 
Mouth Wash (No. 3) 

Sodium Bicarbonate 
Thymol 
Glycerine 
Water 
Normal Salt Solution 

Common Table Salt 
Water 
Boil together for five minutes. 



77 
4 


grains, 
ounces. 


1 

7; 
1 


V 2 grains, 
pint. 


1 
2 


dram, 
drams. 


8 


ounces. 


I 1 / 

1 


2 grains, 
quart. 


1 


dram. 


2 grains. 

1 dram. 

H pint. 


48 

1 


grains, 
pint. 



SELECTED FORMULAS 259 



Mentholated Oil 




Menthol Crystals 


1 ounce. 


Olive Oil 


4 ounces. 


Compound Starch Powder 




Powdered Boric Acid 


3^ dram. 


Powdered Salicylic Acid 


15 grains. 


Corn Starch 


4 ounces, 



CHAPTER XXXIV 
MISCELLANEOUS NOTES 

The Stools. — Green. In gastro-intestinal disease of 
children, excessive flow of bile, after taking calomel. 

Black. — From altered blood, after certain foods as 
spinach, huckleberries; certain medicines as iron, bis- 
muth, tannin, and charcoal. 

Yellow.— -In typhoid fever, certain drugs as senna, 
santonin, and rhubarb. 

Red. — After administering logwood. 

Watery. — In profound diarrheas, cholera, poisoning 
by mercury, arsenic, and antimony. 

Mucous. — In inflammation of the colon, dysentery, 
after prolonged constipation. 

Fatty. — In faulty pancreatic digestion; in the ab- 
sence of bile, as in obliterative jaundice; after the inges- 
tion of an excessive amount of fat. 

Purulent. — From ruptured abscesses of the intestinal 
tract, fistula in ano, dysentery, suppurative enteritis. 

Bloody. — In typhoid fever, ulcers of the intestines, 
dysentery, intussusception, intense anemia, scurvy, 
acute enteritis. 

Expectoration. — Mucous. It is glairy and clear, 
like the white of an egg, and occurs in acute bronchitis, 
asthma, and edema of the lungs. 

Purulent. — In ruptured empyema, abscess of the 
lung, ruptured abscesses of the mediastinum and liver. 

Mucopurulent. — In bronchitis, lobar pneumonia, tu- 
berculosis. 

260 



MISCELLANEOUS NOTES 



26l 



Serous. — In edema of the lungs. 

Bloody. — In beginning pneumonia, tuberculosis, can- 
cer of the lung, congestion of the lung following heart 
disease. 

Pulse. — Rapid. In fevers, tuberculosis, infections, 
exophthalmic goiter, shock, rheumatoid arthritis, loco- 
motor ataxia, valvular heart disease, certain drugs. 

Slow. — In disease of the heart muscle, as fatty de- 
generation; in jaundice; brain tumor; basal meningitis; 
during the convalescence of pneumonia and typhoid 
fever; after drugs, as digitalis, aconite, opium, and 
strophanthus. 



Temperature and Pulse Ratio 

Pulse of 72 corresponds to 98.6°F. 
Pulse of 80-90 corresponds to ioo°F. 
Pulse of 100-115 corresponds to io2°F. 
Pulse of 120-130 corresponds to io4°F. 



First year 
Second year 
3- 6 years 
6-12 years 
Adult life 
Old age 



Pulse at Various Ages 

Respirations = 36 



Pulse = 120 
= 108 



= 84 

= 72 
= 80 



= 30 

= 24 
= 20 
= 18 
= 20 



INDEX 



Abbre\tations, 254 
Abdominal typhus, 87 
Abscess, metastatic, 214 
Acetanilid, antidotes for, 238 
Acid, carbolic, antidotes for, 
238 

hydrocyanic, antidote for, 
238 

uric, in urine, 230 
Acids, antidotes for, 237 
Air, composition of, 25 

for child, 58 

fresh, necessity of, 22 

of sickroom, 25-29 

Albumin in urine, 231 

tests for, 231 

milk, recipe for, 44 

water, recipe for, 42 
Alkalies, antidotes for, 237 
Alkaloids, antidotes for, 237 
Amyl nitrite, antidotes for, 238 
Amyotrophic spinal paralysis, 

156 
Antidotes for acids, 237 

for alkalies, 237 

for alkaloids, 237 

for poisons, 236, 238 

special, 238 
Antiseptic solutions, prepara- 
tion of, 246 
Antiseptics, 245 



Antitoxin, 213, 214 

diphtheria, 183 
ill effects of, 184 
method of administration, 
184 

production of, 215 

unit, 215 

varieties of, 216 
Antityphoid vaccination, 218 
Arrowroot water, recipe for, 42 
Arsenic, antidotes for, 238 
Arthritis as a complication, 80 
Asafcetida enema, 241 
Atrophic spinal paralysis, acute, 

156 
Autumnal fever, 87 

Bacilli, 220, 223 

Bacillus of diphtheria, 175, 224 

of influenza, 147, 224 

of tuberculosis, 225 

of typhoid fever, 88, 223 

paratyphosus, 104 
Bacteria, 220 

classification of, 220 

definition of, 220 

growth of, 221 

media for, 221 

nutrition of, 221 
Bacterial vaccines, 217 
Barley water, recipe for, 42 



263 



264 



INDEX 



Bathing, notes on, 55 
Baths, bed, 52 

foot, 54 

forms of, 50 

in typhoid fever, 99 

mustard, 243 

sheet, 53 

sitz, 54 

sponge, S3 

temperature of, 55 

therapeutic indications, 50 

tub, 50 
Bed bath, 52 

preparation of, in sickroom, 

30 
sores, 64 
as a complication, 81 
causes of, 64 
in typhoid fever, 100 
prevention of, 64 
treatment of, 65 
water, 49 
Bedclo thing, care of, in infec- 
tious diseases, 62 
Beef tea, peptonized, 45 

recipe for, 43 
Belladonna, antidote for, 238 
Bile in urine, 233 

tests for, 233 
Bilious remittent fever, 196 
Biliuria, 227 
Blood in urine, 227 

poisoning, 207 
Boiled custard, recipe for, 45 
Bowel, hemorrhage from, treat- 
ment, 67 
movements in infectious 
diseases, care of, 62 
Bowels, care of, in children, 60 
Bran poultice, 242 



Bread poultice, 242 
Bromids, antidote for, 238 
Bronchitis as a complication, 81 

tent, 145 

treatment of, 65 

Cachexia, malarial, 197 
Camphor as counterirritant, 244 
Carbolic acid, antidotes for, 238 
Carphologia, 82 
Castor oil beans, antidote for, 

238 
Catarrh, epidemic, 147 
Catarrhal fever, 147 
Catheterization, 75 
Centigrade, Fahrenheit equiva- 
lents for, 256 
Cerebrospinal meningitis, 152. 

See also Meningitis. 
Charcoal poultice, 242 
Chicken-pox, 118 

care and management, 119 

diagnosis of, from smallpox, 
112 
Child, care of bowels in, 60 

cleanliness of, 59 

clothing of, 58 

contagious diseases in, isola- 
tion and quarantine 
for, 61 
prevention of, 60 

fever in, 21 

fresh air for, 58 

hygiene, 56-63 

infectious diseases in, preven- 
tion of, 60 

nourishment of, 56 

sleep of, 58 
Chin cough, 142 
Chloral, antidote for, 238 



INDEX 



265 



Chlorids, in urine, 230 
Chloroform and turpentine 

stupes, 244 
Choluria, 227 
Chyluria, 227 
Clam milk, recipe for, 44 
Cleanliness of child, 59 
Clothing, disinfection of, 2 $3 

of child, 58 
Cocaine, antidote for, 238 
Cocoa junket, recipe for, 44 
Coil, cold water, 49 
Cold water coil, 49 
Collapse, treatment of, 78 
Coma vigil, 82 
Complications of fevers, 79 
Constipation, causes of, 65 

treatment of, 66, 102 
Contagious diseases in child, 
isolation and quaran- 
tine for, 61 
prevention of, 60 
Continued fever, 22 
Convulsions as a complication, 
81 

treatment of, 66 
Coqueluche, 142 
Corn-meal gruel, recipe for, 46 
Counterirritation, 242 
Cream of wheat gruel, recipe for, 

46 
Crisis in fevers, 21 

of pneumonia, 168 
Croup, membranous, true, 178 
Croupous pneumonia, 166 
Custard, boiled, recipe for, 45 

Degrees of temperature, 18 
Delirium as a complication, 82 
forms of, 67 



Delirium in typhoid fever, 94, 
103 

treatment of, 67, 103 
Detection of temperature, 19 
Diarrhea as a complication, 82 

treatment of, 66, 102 
Diet in acute articular rheuma- 
tism, 191 
epidemic anterior polio- 
myelitis, 163 

in diphtheria, 182 

in erysipelas, 203 

in fever, 41 

in lobar pneumonia, 171 

in malarial fever, 198 

in measles, 134 

in meningitis, 154 

in scarlet fever, 125 

in smallpox, 116 

in typhoid fever, 97 

in whooping-cough, 145 

of sick, 33, 42 
Digitalis, antidote for, 239 
Diphtheria, 175 

antitoxin in, 180, 181, 183 

bacillus of, 175, 224 

care and management, 180 

carriers, 175 

complications of, 179 

definition of, 175 

diet in, 182 

etiology of, 175 

intubation in, 185 

of larynx, 178 

of nose, 178 

prognosis of, 180 

quarantine in, 187 

sequels of, 179 

symptoms of, 1 76 

transmission of, 180 



266 



INDEX 



Diphtheria, treatment of, 183 
Diplococcus. 220 

intracellularis meningitidis. 
223 
Discharges, care of, 248, 249 
Dishes, care of, in infectious 

diseases, 62 
Disinfection, 245 

methods of, 129 

of clothing, 253 

of rooms. 250 

sulphur, 251 

with formaldehyd gas, 129, 
252 
Donne's test for pus in urine. 

233 
Draughts in sickroom, danger. 

26 
Drugs causing temperature fall. 
18 
rise, 18 
toxic action of, 234 

Edema of lungs as a complica- 
tion, 82 
Eggnog, recipe for, 45 
Eggs as food, 41 
Emesis. See Vomiting. 
Emetics in poisoning, 236 
Endocarditis, as complication, 

S3 
Enemata, 240 
asafcetida, 241 
glycerine, 240 
nutritive, 240 
oil, 240 
oxgall, 240 
purgative, 240 
quassia, 241 
saline, 240 



Enemata, soapsuds, 240 

starch and laudanum, 241 

turpentine. 241 

uses of. 240 
Enteric fever, 87. See also 

Typhoid fever. 
Enteroclysis. 71 

technic of. 72 
Epidemic catarrh, 147 

cerebrospinal meningitis. 152 

parotitis, 140. See also 
Mumps. 

poliomyelitis, 156 

roseola, 137 
Epistaxis. 68, 102 
Eruption of German measles, 
138 

of measles, 133 

of scarlet fever, 121 

of smallpox, in 

of typhoid fever, 92 
Erysipelas, 201 

care and management of, 
202 

complications of, 80, 202 

definition of, 201 

diet in, 203 

etiology of, 201 

prognosis of, 202 

symptoms of, 201 
Estivo-autumnal fever, 196 
Expectoration, significance of, 

260, 261 

Fahrenheit, centigrade equiva- 
lents for, 256 
Fall fever, 87 

Farina gruel, recipe for, 46 
Fastigium, the, 21 
Feces. See Stools. 



INDEX 



267 



Feeding, frequency of, 34 
Fehling's test for sugar in urine, 

232 
Fever, antemortem, 21 
complications of, 79 
continued, 22 
definition of, 17 
detection of, 19 
in children, 21 
in pneumonia, 168. See 

also Pneumonia. 
in rheumatism, 189. See 

also Rheumatism. 
in smallpox, 210. See also 

Smallpox. 
in typhoid fever, 74. See 
also Typhoid fever. 
diet, 41 

intermittent, 22 
invasion period of, 21 
phenomena of, 22 
prognosis of, 20 
reduction of, 48 
remittent, 22 
stages of, 21 
treatment of, 22 
types of, 22 
Fibrinous pneumonia, 166 
Fievre rouge, 120 
Flaxseed poultice, 242 

tea, recipe for, 43 
Flies, exclusion of, from sick- 
room, 248 
Food, definition of, 33 
Foodstuff, definition of, 33 
Foot baths, 54 
Formaldehyd disinfection, 129, 

252 
Formulas, selected, 257 
French measles, 137 



Furniture of sickroom, 29 

Gelatine, recipe for, 47 
German measles, 137. See also 

Measles, German. 
Glycerine enemata, 240 
Glycosuria, 232 
Gmelin's test for bile in urine, 

233 
Grippe pneumonia, 149 

Haines' test for sugar in urine, 

233 
Hands, care of, in infectious 

diseases, 62 
Headache, treatment of, 67 
Hematuria, 227 

Hemorrhage from bowel as a 
complication, 83 
occurrence of, 67 
treatment of, 67 

from lungs, treatment of, 68 

from nose, treatment, 68 
Hybrid scarlet fever, 137 
Hydrocyanic acid, antidote for, 

238 
Hydrotherapy, definition of, 48 

in typhoid fever, 99 

methods of, 48 
Hygiene, child, 56-63 
Hypodermoclysis, 69 

indications for, 70 

technic of, 70 

Ice poultice, 49 
Ice-bag, uses of, 48 
Immunity, 213 
Imperial drink, recipe for, 43 
Infantile paralysis, 156 
Infectious disease in child, pre- 
vention of, 60 



INDEX 



Influenza, 147 

bacillus, 224 

care and management, 143 

complications of, 140 

convalescence from, 150 

course of, 148 

definition of, 147 

etiology of. 147 

forms of, 147 

prognosis of. 149 

sequels of. 148 

symptoms of, 147 

synonyms of, 147 
Insomnia, treatment of, 68 
Intermittent fever, 22 
Intestinal hemorrhage as a com- 
plication, 83 

perforation as complication. 

84 
Intubation in diphtheria, 185 
Iodine as counterirritant, 244 
Isolation and quarantine for 
contagious diseases in chil- 
dren. 61 

Junket, cocoa, recipe for, 44 
recipe for, 44 

Kerxig's sign in meningitis, 

153 
Kerosene as counterirritant, 244 
Keuchhusten, 142 
Kilmer belt in whooping-cough . 

146 
Koplik's spots in measles, 132 
Kumiss, recipes for. 45 

La grippe, 147. See also 

Influenza. 
Larynx, diphtheria of, 178 



Laudanum and starch enema, 

241 
Lead compounds, antidotes for, 

239 
Lime water, recipe for, 43 
Lobar pneumonia, 166. See 

a\soPneumo)iia, lobar. 
Luap, recipe for, 45 
Lumbar puncture in meningitis. 

Lung fever, 166 

Lungs, edema of, as a complica- 
tion, 82 
hemorrhage from, treatment, 
68 

Lysis in fevers, 21 

Malarial fever, 193 
cachexia of, 197 
care and management of, 

197 
chronic, 197 
diet in, 198 
etiology of, 193 
mosquito in, 197 
pernicious, 196 
prognosis of, 197 
remittent, 196 
stages of, 193 
symptoms of, 193 
varieties of, 196 
Mania a potu, 82 
Masern, 131 
Measles, 131 
care and management of, 134 
complications of, 134 
definition of, 131 
diet in, 134 
French. 137 
German, 137 



INDEX 



269 



Measles, German, complica- 
tions of, 138 
desquamation in, 138 
diagnosis of, 138 
eruption of, 138 
etiology of, 137 
management of, 139 
measly form, 138 
prognosis of, 138 
scarlatinal form, 138 
symptoms of, 137 
synonyms of, 137 
Koplik's spots in, 132 
quarantine in, 136 
rash in, 133 
symptoms of , 131 
Measures and weights, 254 
Meat as food, 41 
jelly, recipe for, 43 
juice, recipe for, 44 
Membranous croup, true, 178 
Meningitis, cerebrospinal, 152 
care and management, 154 
complications of, 153 
convalescence from, 155 
course of, 153 
diagnostic points, 153 
diet in, 154 
etiology of, 152 
Kernig's sign in, 153 
lumbar puncture in, 153 
prognosis of, 153 
symptoms of, 152 
Mercury, antidotes for, 239 
Metastatic abscess, 214 
Micrococci, 220, 221 

varieties of, 220 
Milk, albumen, recipe for, 44 
as food, 34 
for children nine to twelve 
months, 41 



Milk, as food for children, 
one to three months, 40 
six to nine months, 40 
three to six months, 40 
under twelve months, 39 

clam, recipe for, 44 

daily amount of, 35 

in typhoid fever, 96 

modification for infant feed- 
ing, 35 

objections to, 35 

oyster, recipe for, 44 

pasteurized, 96 

peptonized, recipe for, 45 

punch, recipe for, 44 

sterilized, 96 
Morbilli, 131 
Mouth, care of, 67, 101 

disorders of, 67 

wash, 67 

excretions from, care of, in 
infectious diseases, 62 
Movements, bowel, 260. See 

also Stools. 
Mumps, 140 

complications of, 141 

course of, 141 

management of, 141 

symptoms of, 140 
Mustard bath, 243 

pack, 243 

plaster, 243 

poultice, 242 

Nephritis as complication, 84 

treatment of, 69 
Nitrite of amyl, antidotes for, 

Nose, diphtheria of, 178 
excretions from, care of, in 
infectious diseases, 62 



270 



INDEX 



Nose, hemorrhage from, treat- 
ment, 68 
Nosebleed, 68, 102 
Nourishment of child, 56 
Nutritive enema, 240 

Oatmeal water, recipe for, 42 

Oil enemata, 240 

Oliguria, 227 

Opium, antidotes for, 239 

Otitis media as complication, 

85 
Oxgall enemata, 240 
Oyster milk, recipe for, 44 
Oysters, peptonized, 46 

Pack, mustard, 243 

Packs, sheet, 53 

Pains in back, treatment of, 73 

in joints, treatment of, 73 
Paralysis, acute atrophic spinal, 
156 
amyotrophic spinal, 156 
as complication, 85 
infantile, 156 
spinal, 156 
Paratyphoid fever, 104 
complications, 107 
diagnosis, 108 
etiology, 104 
historical, 104 
prodromes, 105 
prognosis, 107 
symptoms, 105 

alimentary, 105 
temperature in, 107 
treatment, 109 
Parotitis, epidemic, 140. See 

also Mumps. 
Pasteurized milk, 96 



Peptonized beef tea, 45 
milk, recipe for, 45 
oysters, 46 
toast, 46 
Perforation, intestinal, as com- 
plication, 84 
Pericarditis as complication, 85 
Peritonitis, treatment of, 74 
Pertussis, 142. See also Whoop- 
ing-cough. 
Phenomena of fevers, 22 
Phlebitis as complication, 8s 
Phosphates in urine, 230 
Phosphorus, antidotes for, 239 
Plants in sickroom, removal of, 

30 
Plaster, mustard, 243 
Pleurisy as complication, 86 

treatment of, 74 
Pleuropneumonia, 166 
Pneumococcus, 166, 223 
Pneumonia as complication, 86 
croupous, 166 
fibrinous, 166 
grippe, 149 
lobar, 166 

care and management of, 

170-173 
chill in, 167 
complications of, 169 
convalescence in, 174 
cough in, 167 
course of, 170 
crisis in, 168 
definition of, 166 
diet in, 171 
endocarditis in, 170 
etiology of, 166 
fever in, 168 
herpes labialis in, 168 



INDEX 



271 



Pneumonia, lobar, pathology 
of, 166 
pericarditis in, 160 
prognosis of, 170 
sputum in, 167 
symptoms of, 167 
synonyms of, 166 
urine in, 168 
varieties of, 169 
Pneumonitis, 166 
Poisoning, acute, treatment of, 
236 
blood, 207 
Poison-ivy, antidotes for, 239 
Poisons and antidotes, 236 
method of rendering inert, 236 

to counteract, 237 
removal of, 236 
Poliomyelitis, acute epidemic 
anterior, 156 
anatomical seat of le- 
sion, 156 
baths in, 164 
bone dystrophies in, 160 
care and management, 

161 
clothing in, 163 
contractures in, 160 
convulsions in, 159 
definition, 156 
diagnosis, 161 
diet in, 163 
electrical reaction in, 

161 
etiology, 156 
gait in, 160 
motor symptoms, 158 
muscle tone in, 1 59 
muscular atrophy in, 
160 



Poliomyelitis, paralysis in, 158 
reflexes in, 159 
rubbing in, 164 
sensory symptoms, 160 
symptoms, 157 
synonyms, 156 
trophic disorders in, 
160 
Polyuria, 227 
Poultices, 242 
bran, 242 
bread, 242 
charcoal, 242 
flaxseed, 242 
ice, 49 

mustard, 242 
uses of, 242 
Preparation of bed in sick- 
room, 30 
Pulse at various ages, 261 
in typhoid fever, 93 
rapid, significance of, 261 
ratio, temperature and, 261 
slow, significance of, 261 
Purgative enemata, 240 
Pus in urine, 233 
tests for, 233 
Pyemia, 206, 214 
definition of, 206 
etiology of, 207 
symptoms of, 207 
treatment of, 208 

Quarantine for contagious dis- 
eases in children, 61 

in diphtheria, 187 

in measles, 136 

in scarlet fever, 128 
Quassia enema, 241 
Quiet in sickroom, 31 



272 



INDEX 



Rash. See Eruption. 

Rectal drop infusion of saline 
solution, 73 

Red fever, 120 

Remittent fever, 22 

Retention of urine, 75 

Rheumatism, acute articular, 
188 
care and management of, 

190 
complications of, 189 
convalescence from, 102 
course of, 190 
diet in, 191 
etiology of, 188 
fever in, 189 
symptoms of, 189 
temperature in, 189 

Rice water, recipe for, 43 

Room, sick, 25. See also Sick- 
room. 

Rooms, disinfection of, 250 

Roseola, epidemic, 137 

Rotheln, 137. See als Measles, 
German. 

Rougeole, 131 

Rubella, 131, 137 

Saline solution, injection of, 
69 
indications for, 70 
technic, 70 
rectal drop infusion of, 73 
Sapremia, 206, 214 

etiology of, 207 
Sarcinae, 220 

Scarlatina, 120. See also Scar- 
let fever. 
Scarlatinal form of German 
measles, 138 



Scarlet fever, 120 
black, 123 
care and management of, 

124 
complications of, 122 
desquamation in, 122 
diet in, 125 
disinfection after, 129 
eruption of, 121 
fever in, 122 
hybrid, 137 
quarantine in, 128 
sequels of, 122 
strawberry tongue in, 122 
symptoms of, 1 20 
Scharlach, 120 
Septicemia, 206, 214 
care and management of, 208 
definition of, 206 
etiology of, 207 
symptoms of, 207 
Sheet bath, 53 

packs, S3 
Shock, treatment of, 78 
Sickroom, air of . 25-29 
care of, 247 

draughts in, danger of, 26 
furniture of, 29 
hygiene of, 25-32 
location of, 29 
plants in, removal of, 30 
preparation of bed in, 30 
quiet in, 31 
selection of, 29 
temperature of, 29 
ventilation of, 25 
Sitz bath, 54 
Sleep of child, 58 
Smallpox, no 
care and management of, 112 



INDEX 



273 



Smallpox, complications of, 79, 
112 

confluent, in 

definition of, 1 10 

diagnosis of, from chicken- 
pox, 112 

diet in, 116 

eruption of, in 

etiology of, no 

fever in, no 

hemorrhagic, 112 

initial rash in, no 

isolation in, 115 

pitting in, 116 

prognosis of, 112 

symptoms of, no 

vaccination in, 112 

varieties of, in 
Soapsuds enemata, 240 
Solutions, antiseptic, prepara- 
tion of, 246 
Sore throat, treatment of, 76 
Specific gravity of urine, 229 
Spinal infantile paralysis, 156 

paralysis, acute atrophic, 
156 
amyotrophic, 156 
Spirilla, 221 
Sponge bath, 53 
Spotted fever, 152 
Stages of fever, 21 
Staphylococcus, 220 

pyogenes albus, 223 
aureus, 221 
citreus, 223 
Starch and laudanum enema, 

241 
Stools, care of, in infectious 
diseases, 62 

clinical significance of, 260 



Stools, color of, 260 

in typhoid fever, 97 
Strawberry tongue, 122 
Streptococcus, 220 

pyogenes, 223 
Strychnine, antidotes for, 239 
Stupes, 244 

chloroform and turpentine, 
244 

turpentine, 243, 244 
Sugar in urine, 232 

tests for, 232 
Sulfonal, antidotes for, 239 
Sulphur disinfection, 251 
Sweating, treatment of, 76 

Tapioca gruel, recipe for, 47 
Temperature and pulse ratio, 
261 

degrees of, 18 

detection of, 19 

in typhoid fever, 90 

of baths, 55 

rectal, 20 

variations of, 17 
Thermometer, uses of, 19 
Thermometric equivalents, 256 
Throat, sore, treatment of, 76 
Thrombosis as complication, 86 
Toast, peptonized, 46 

water, recipe for, 43 
Tongue, disorders of, 67 
Topical applications, 242 
Toxemia, 206, 214 

care and management of, 
208 

definition of, 206 

etiology of, 207 

symptoms of, 207 
Toxin unit, 215 



274 



INDEX 



Toxins, elimination of, methods, 

209, 210 
Tub bath, 50 
Tuberculin, 225 
Tuberculosis, bacillus of, 225 
Turpentine and chloroform 

stupes, 244 
enema, 241 
stupe, 243, 244 
Tympanites, treatment of, 76, 

93, 102 
Types of fever, 22 
Typhoid fever, 87 

bacillus of, 8&, 223 

baths in, 99 

bed sores in, 100 

care and management of, 95 
of mouth in, 101 

carriers of, 89 

causes of, 87 

circulatory system, 93 

clothing in, 96 

complications of, 79 

constipation in, 102 

convalescence from, 103 

countenance in, 92 

delirium in, 94, 103 

diagnosis of, 94 

diarrhea in, 93, 102 

diet in, 97 

digestive system in, 93 

disinfection of stools in, 97 

epistaxis in, 102 

eruption of, 92 

etiology of, 87 

fever in, 99 

milk in, 96 

muscles in, 93 

nausea and vomiting in, 
101 

nervous system in, 94 

prevention of, 89 



Typhoid fever, prognosis of, 

95 m 
pulse in, 93 

respiratory tract in, 93 
sordes in, 93 
spleen in, 92 
stools in, 92, 97 
symptoms of, 90 
synonyms of, 87 
temperature in, 90 
tongue in, 92 
tympanites in, 93, 102 
urine in, 94, 97 
vomiting in, 93, 101 
water in, 88, 95 
Widal reaction in, 223 
vaccine, 218 
Typhus, abdominal, 87 

Urates in urine, 230 
Urea in urine, 229 
Uric acid in urine, 230 
Urine, albumen in, 231 
tests for, 231 

amount voided, 226 

bile in, 233 
tests for, 233 

blood in, 227 

care of, in infectious diseases, 
62 

chlorids in, 230 

collection of, 226 

color of, 227 

constituents of, 229 

density of, 229 

examination of, 226 

in typhoid fever, 97 

odor of, 228 

phosphates in, 230 

properties of, 226 

pus in, 233 
tests for, 233 



INDEX 



275 



Urine, reaction of, 229 
retention of, 75 
specific gravity of, 229 
sugar in, 232 

tests for, 232 
urates in, 230 
urea in, 229 
uric acid in, 230 

Vaccination, 112 

antityphoid, 218 

importance of, 113 

method of, 1 14 

signs of, 115 
Vaccines, bacterial, 217 
Variola, 1 10. See also Smallpox. 
Varioloid, 112. See also Small- 
pox. 
Ventilation, methods of, 26 

of sickroom, 25 

window, 27, 28 
Veratrum, antidote for, 239 
Vomiting, treatment of, 77, 93, 



Water, albumen, 42 

arrowroot, 42 

barley, 42 

bed, 49 

coil, 49 

lime, 43 

oatmeal, 42 

rice, 43 

toast, 43 
Weights and measures, 254 
Whey, 44 

wine, 44 
Whispering in sickroom, 31 
Whooping-cough, 142 

care and management of, 
144 

complications of, 80, 144 

diet in, 145 

sequels of, 144 

symptoms of, 142 

synonyms of, 142 
Widal reaction in typhoid fever, 

223 
Wine whey, 44 



Books for Nurses 



PUBLISHED BY 



W. B. SAUNDERS COMPANY 

West Washington Square Philadelphia 

London: 9, Henrietta Street, Covent Garden 



Sanders' Nursing 



A NEW WORK 



Miss Sanders' new book is undoubtedly the most 
complete and most practical work on nursing ever 
published. Everything about every subject with 
which the nurse should be familiar is detailed in 
a clean cut, definite way. There is no other 
nursing book so full of good, practical informa- 
tion — information you need. 

Modern Methods in Nursing. By GEORGIANA J. SANDERS, 
formerly Superintendent of Nurses at Massachusetts Gen- 
eral Hospital. i2mo of 881 pages, with 227 illustrations. 

Cloth, $2.50 net. 

Aikens' Home Nurse's Handbook 

PRACTICAL 

The point about this work is this: It tells you, 
and shows you just how to do those little — but 
none the less important— things entirely omitted 
from other nursing books, or at best only inci- 
dentally treated. The chapters on "Home Treat- 
ments" and "Every-Day Care of the Baby," 
stand out as particularly practical. Then the 
"Points to be Remembered" — terse, crisp re- 
minders — -is a feature of great value. 

Home Nurse's Handbook. By Charlotte A. Aikens, 
formerly Director of the Sibley Memorial Hospital, Wash- 
ington, D.C. i2tno of 276 pages, illustrated. Cloth. $1.50 nei 



Stoney's Nursing 



NEW (4th) EDITION 



Of this work the American Journal of Nursing says: "It is the 
fullest and most complete and may well be recommended as 
being of great general usefulness. The best chapter is the one 
on observation of symptoms which is very thorough." There 
are directions how to improvise everything. 

Practical Points in Nursing. By Ea\ily M. A. Stoney, formerly Super- 
intendent of the Training School for Nurses in the Carney Hospital, 
South Boston, Mass. nmo, 495 pages, illustrated. Cloth, $1.75 net. 



NEW (3d) EDITION 



Stoney's Materia Medica 

Stoney's Materia Medica was written by a head nurse who 
knows just what the nurse needs. American Medicine says 
it contains "all the information in regards to drugs that a 
nurse should possess." 

Materia Medica for Nurses. By Emily M. A. Stoney, formerly Super- 
intendent of the Training School for Nurses in the Carney Hospital, 
South Boston, Mass. i2mo volume of 300 pages. Cloth, $1.50 net. 



NEW (3d) EDITION 



Stoney's Surgical Technic 

The first part of the book is dovoted to Bacteriology and 
Antiseptics; the second part to Surgical Technic, Signs of 
Death, Bandaging, Care of Infants, etc. 

Bacteriology and Surgical Technic for Nurses. By Emily M. A. 
Stoney. Revised by Frederic R. Griffith, M. D., New York. 
i2mo volume of 311 pages, fully illustrated. Cloth, $1.50 net. 

Goodnow's First-Year Nursing illustrated 

Miss Goodnow's work deals entirely with the practical side of 
first-year nursing work. It is the application of text-book 
knowledge. It tells the nurse how to do those things she is called 
upon to do in her first year in the training school — the actual 
ward work. 

First-Year Nursing. By Minnie Goodnow, R. N., formerly Super- 
intendent of the Women's Hospital, Denver. Mmo of 328 pages, 
illustrated. Cloth, $1.50 net. 



Aikens' Hospital Management 

This is just the work for hospital superintendents, training- 
school principals, physicians, and all who are actively inter- 
ested in hospital administration. The Medical Record says: 
"Tells in concise form exactly what a hospital should do 
and how it should be run, from the scrubwoman up to its 
financing." 

Hospital Management. Arranged and edited by Charlotte A. 
Aikens, formerly Director o Sibley Memorial Hospital, Washing- 
ton, D. C. i2mo of 488 pages, illustrated. Cloth, $3.00 net 



JUST READY 
NEW (3d) EDITION 



Aikens' Primary Studies 

Trained Nurse and Hospital Review says: "It is safe to say 
that any pupil who has mastered even the major portion of 
this work would be one of the best prepared first year pupils 
who ever stood for examination." 

Primary Studies for Nurses. By Charlotte A. AlKENS, formerly 
Director of Sibley Memorial Hospital, Washington, D. C. i2mo of 
471 pages, illustrated. Cloth, $1.75 net. 

Aikens' Training-School Methods and 
the Head Nurse 

This work not only tells how to teach, but also what should 
be taught the nurse and how much. The Medical Record says: 
" This book is original, breezy and healthy." 

Hospital Training-School Methods and the Head Nurse. By Char- 
lotte A. Aikens, formerly Director of Sibley Memorial Hospital, 
Washington, D. C i2mo of 267 pages. Cloth, $1.50 net, 

Aikens' Clinical Studies NEW (2d) EDmoN 

This work for second and third year students is written on the 
same lines as the author's successful work for primary stu- 
dents. Dietetic and Hygienic Gazette says there "is a large 
amount of practical information in this book." 

Clinical Studies for Nurses. By CHARLOTTE A. Aikens, formerly 
Director of Sibley Memorial Hospital, Washington, D. C. i2mo of 
56g pages, illustrated Cloth, $2.00 net 



Bolduan and Grund's Bacteriology 

The authors have laid particular emphasis on the immediate 
application of bacteriology to the art of nursing. It is an 
applied bacteriology in the truest sense. A study of all the 
ordinary modes of transmission of infection are included. 

Applied Bacteriology for Nurses. By Charles F. Bolduan, M.D., 
Assistant to the General Medical Officer, and MARIE GRUND, M.D., 
Bacteriologist, Research Laboratory, Department of Health, City of 
New York. i2mo of 166 pages, illustrated. Cloth, $1.25 net. 



Fiske's The Body 



A NEW IDEA 



Trained Nurse and Hospital Review says "it is concise, well- 
written and well illustrated, and should meet with favor in 
schools for nurses and with the graduate nurse." 

Structure and Functions of the Body. By Annette Fiske, A. M., 

Graduate of the Waltham Training School for Nurses, Massa- 
chusetts. i2mo of 221 pages, illustrated. Cloth, $1.25 net 



Beck's Reference Handbook 



NEW (3d) EDITION 



This book contains all the information that a nurse requires 
to carry out any directions given by the physician. The 
Montreal Medical Journal says it is "cleverly systematized and 
shows close observation of the sickroom and hospital regime.'' 

A Reference Handbook for Nurses. By Amanda K. Beck, Grad* 
uate of the Illinois Training School for Nurses, Chicago, 111. 
32010 volume of 244 pages. Bound in flexible leather, $1.25 net 

Roberts' Bacteriology & Pathology 

This new work is practical in the strictest sense. Written 
specially for nurses, it confines itself to information that the 
nurse should know. All unessential matter is excluded. The 
style is concise and to the point, yet clear and plain. The text 
is illustrated throughout. 

Bacteriology and Pathofogy for Nurses. By Jay G. Roberts, Ph. G., 
M. D., Oskaloosa, Iowa, nmo of 206 pages, illustrated. $1.25 net. 



DeLee's Obstetrics for Nurses ed.™! 

Dr. Del^ee's book really considers two subjects — obstetrics 
for nurses and actual obstetric nursing. Trained Nurse and 
Hospital Review says the "book abounds with practical 
suggestions, and they are given with such clearness that 
they cannot fail to leave their impress." 

Obstetrics for Nurses. By JOSEPH B. DeLee, M. D., Professor of 
Obstetrics at the Northwestern University Medical School, Chicago. 
i2mo volume of 508 pages, fully illustrated. Cloth, $2.50 net. 

Davis' Obstetric & Gynecologic Nursing 

NEW (4th) EDITION 

The Trained Niirse and Hospital Review says: " This is one 
of the most practical and useful books ever presented to the 
nursing profession." The text is illustrated. 

Obstetric and Gynecologic Nursing. By EDWARD P. Davis, M. D., 
Professor of Obstetrics in the Jefferson Medical College, Philadel- 
phia. i-2mo volume of 480 pages, illustrated. Buckram, $1.75 net. 

Macfarlane's Gynecology for Nurses 

NEW (2d) EDITION 

Dr. A. M. Seabrook, Woman's Hospital of Philadelphia, says: 
"It is a most admirable little book, covering in a concise but 
attractive way the subject from the nurse's standpoint." 

A Reference Handbook of Gynecology for Nurses. By Catharine 
Macfarlane, M. D., Gynecologist to the Woman's Hospital of Phila- 
delphia. 32mo of 156 pages, with 70 illustrations. Flexible leather, 
$1.25 net. 



Asher's Chemistry and Toxicology 

Dr. Asher's one aim was to emphasize throughout his book 
'the application of chemical and toxicologic knowledge in the 
study and practice of nursing. He has admirably succeeded. 

i2mo of 190 pages. By Philip Asher, Ph. G., M. D., Dean and Pro- 
fessor of Chemistry, New Orleans College of Pharmacy. Cloth, 
$1.25 net. 



Bohm & Painter's Massage 

The methods described are those employed in Hoffa's Clinic 
— methods that give results. Every step is illustrated, showing 
you the exact direction of the strokings. The pictures are 
large. 

Octavo of qi pages, with 97 illustrations. By Max Bohm, M. D., 
Berlin, Germany. Edited by Charles F. Painter, M. D., Professor 
of Orthopedic Surgery, Tufts College Medical School, Boston. 

Cloth, $1.75 net. 

Eye, Ear, Nose, and Throat Nursing 

Medical Record says: " Every side of the question has been 
fully taken into consideration." 

Nursing in Diseases of the Eye, Ear, Nose and Throat. By the 
Committee on Nurses of the Manhattan Eye, Ear and Throat Hospital. 
i2mo of 260 pages, illustrated. Cloth, $1.50 net. 

Friedenwald and Ruhrah's Dietetics for 

i\ lirSGS NEW (3d) EDITION 

This work has been prepared to meet the needs of the nurse, 
both in training school and after graduation. American Jour- 
nal of Nursing says it "is exactly the book for which nurses 
and others have long and vainly sought." 

Dietetics for Nurses. By Juu'us Friedenwald, M. D., Professor 
of Diseases of the Stomach, and John RuhRAH, M. D., Professor of 
Diseases of Children, College of Physicians and Surgeons, Baltimore. 
i2mo volume of 431 pages. Cloth, $1.50 net 

Friedenwald & Ruhrah on Diet edition 

Diet in Health and Disease. By Julius Frieden- 
wald, M.D., and John Ruhrah, M.D. Octavo vol- 
ume of 857 pages. Cloth, $4.00 net. 

Galbraith's Personal Hygiene and Physical 
Training for Women illustrated 

Personal Hygiene and Physical Training for Women. By ANNA M. 
Galbraith, M. D., Fellow New York Academy of Medicine. 121110 
of 371 pages, illustrated. Cloth, $2.00 net. 

Galbraith's Four Epochs of Woman's Life 

THE NEW (2d) EDITION 

The Four Epochs of Woman's Life. By Anna M. Galbraith, M.D. 
With an Introductory Note by John H. MuSSER, M. D., University 
of Pennsylvania, nmo of 247 pages. Cloth, $1.50 net 



McCombs' Diseases of Children for Nurses 

NEW (2d) EDITION 

Dr. McCombs' experience in lecturing to nurses has enabled 
him to emphasizey?^/ those points thai nurses most 7ieed to k?ww. 
National Hospital Record says: "We have needed a good 
book on children's diseases and this volume admirably fills 
the want." The nurse's side has been written by head 
nurses, very valuable being the work of Miss Jennie Manly. 

Diseases of Children for Nurses. By Robert S. McCombs, M. D., 
Instructor of Nurses at the Children's Hospital of Philadelphia. i2mo 
of 470 pages, illustrated. Cloth, $2.00 net 

Wilson's Obstetric Nursing NEW w edition 

In Dr. Wilson's work the entire subject is covered from the 
beginning of pregnancy, its course, signs, labor, its actual 
accomplishment, the puerperium and care of the infant. 
American Journal of Obstetrics says: " Every page empasizes 
the nurse's relation to the case." 

A Reference Handbook of Obstetric Nursing. By W. Reynolds 
Wilson, M.D., Visiting Physician to the Philadelphia Lying-in Char= 
?ty\> 32010 of 355 pages, illustrated. Flexible leather, $1.25 net 



JUST READY 
NEW (9th) EDITION 



American Pocket Dictionary 

The Trained Nurse and Hospital Review says: "We have 
had many occasions to refer to this dictionary, and in every 
instance we have found the desired information." 

American Pocket Medical Dictionary. Edited by W. A. Newman 
Dorland, A. M., M. D., Loyola University, Chicago. Flexible 
leather, gold edges, $1.00 net; with patent thumb index, $1.25 net. 



THIRD 
EDITION 



Lewis' Anatomy and Physiology 

Nurses J oamal of Pacific Coast says "it is not in any sense 
rudimentary, but comprehensive in its treatment of the sub- 
jects.' ' The low price makes this book particularly attractive. 

Anatomy and Physiology for Nurses. By LeRoy Lewis, M.D., Lec- 
turer on Anatomy and Physiology for Nurses, Lewis Hospital, Bay 
City, Mich. i2mo of 326 pages, 150 illustrations. Cloth, $1.75 net 



Boyd's State Registration for Nurses 

State Registration for Nurses. By LOUIE CROFT Boyd, R. N., Grad- 
2d EDITION uate Colorado Training School for Nurses. Cloth, $1.25 net. 

Paul's Materia Medica NE w ^ edition 

A Text-Book of Materia Medica for Nurses. By George P. Paul, M.D., 
Samaritan Hospital, Troy, N. Y. i2mo of 282 pages. Cloth, $1.50 net. 

Paul's Fever Nursing NEW (2 d> edition 

Nursing in the Acute Infectious Fevers. By GEORGE P. Paul, M.D. 
i2mo of 246 pages, illustrated. Cloth, $1.00 net. 

Hoxie & Laptad's Medicine for Nurses 

NEW (2d) EDITION, REWRITTEN 

Medicine for Nurses and Housemothers. By GEORGE Howard 
Hoxie, M.D., University of Kansas; and Pearl L. Laptad. i2mo 
of 351 pages, illustrated. Cloth, $1.50 net. 

SECOND 
EDITION 



Grafstrom's Mechano-therapy 

Mechano-therapy (Massage and Medical Gymna 
Grafstrom, B.Sc. M.D., i2mo, 200 page;,. 

Nancrede's Anatomy new aih) edition 

Essentials of Anatomy. Charles B. G. deNancrede, M.D., Univers- 
ity of Michigan. i2mo, 490 pages, 180 illustrations. Cloth, $1.00 nei. 

Morrow's Immediate Care of Injured 

Immediate Care of the Injured. By 1 
York City Home for Aged and Inl 
242 illustrations. Clotr, $2.50 let. 

Register's Fever Nursing 

A Text Book on Practical Fever Nu*s 
M.D., North Carolina Medical CoIK> 
trated. 

Pyle's Personal Hygiene 



Mechano-therapy (Massage and Medical Gymnastics). By Axel V $ 
Grafstrom, B.Sc. M.D., 121110, 200 page;,. Cloth, $1.25 net. 



Immediate Care of the Injured. By Albert S. MORROW, M.D., New 
York City Home for Aged and Infirm. Octavo of 354 pages, with 
242 illustrations. Clotr, $2.50 net. New (2d) Edition 



A Text Book on Practical Fever Nu-sing. By Edward C. Register, 
M.D., North Carolina Medical College. Octavo of 350 pages, illus- 
trated. Cloth, $2.<;o net. 



JUST OUT 
NEW (6th) EDITION 



A Manual of Personal Hygiene. Edited by Walter L. Pyle, M.D. 

Wills Eye Hospital, Philadelphia. i2mo, 543 pages, illus. $1.50 net. 



Morris' Materia Medica 



NEW (7th) EDITION 

Essentials of Materia Medica, Therapeutics, and Prescription Writing. 
By Henry Morris, M.D. Revised by W. A. Bastedo, M.D., Colum- 
bia University, N. Y. i2mo of 300 pages, illustrated. Cloth, $1.00 net 



Griffith's Care of the Baby 



JUST OUT 
NEW (6th) EDITION 



The Care of the Baby. By J. P. Crozer Griffith, M.D. , Univers- 
ity of Pennsylvania. i2mo of 45& pages, illustrated. Cloth, $1.50 net. 



